Branding & Brand Loyalty

How does self image tie to brand loyalty?  Can we tie that to PT?

So I've started reading for fun again, finally.  I enjoy reading about incentives and decision making. The human capacity to fool itself amazes me.    My first brain-toy is this:  You Are Not So Smart.  It started as a blog written by @davidmcraney.  He's a journalist who writes about things that are fun and interesting.  I recommend checking out the blog or book!  

One chapter in his book stood out as relevant to some of the #SolvePT discussions. Craney pointed out that brand loyalty is created from buying (or buying into) unessential things - iPads or your favorite brand of smart phone. To oversimplify his point, spending a lot on something you don't need forces you to create a narrative in your mind about why you made the best decision for you.  A higher cost means a stronger internal justification.  It sounds to me like the effect lies somewhere between cognitive dissonance and confirmation bias.  Your unconscious interests in justifying your decisions tie directly to your own self image.  You are forced, after making the decision, to create a narrative supporting the decision. And ownership reinforces the emotional connection to "stuff."

Can physical therapy be stuff? Should it be?  Probably NOT.  I feel like the fact that we do not create the same brand loyalty to PT is a testament to our USEFULNESS.  Not to say that an iPad can't be useful,  but when you need physical therapy you definitely NEED physical therapy.  You never really NEED a new tablet. I am probably reaching here, but the idea of entitlement to PT via health insurance, and a client/patient's reluctance to pay for PT out of pocket definitely hurts our cause.  You lose the benefit of cognitive dissonance.  I am paying for PT, so I must value it!  

What's weird to me is the attachment people have to their chiropracters.  Does that the kind of brand loyalty Craney describes insinuates an unthinking devaluation of chiropractic care?  Craney also points out that for brand loyalty to occur, you must have OPTIONS, or a decision to make.  Reducing the # of options reduces buyer's remorse.  People LOVE their chiropracters and accupuncturists, and pay out of pocket for other services because they KNOW they have a choice!  The public is aware that they can go to a chiropracter first.  

Lets see if I can tie this together to make my point.  I am NOT saying we need to create a preception that people don't need us so that they have to justify going to see a physical therapist.  I'm saying we need to increase AWARENESS that we are a CHOICE, not just a place patients go because the workman's comp physician sent them to us. We need to give patients/clients/the public the opportunity to make [the right] decision about PT to allow self-image-affirmation to take over.  I think, too, that building a client/patient a reason to be more comfortable paying out of pocket will strengthen this bond.  Is this even possible???

Is anybody having success trying to create a self-paying base of patients/clients?


Your Carharts...

...should have to be checked in!

I just finished reading my National Physical Therapy Exam again courtesy of the FSBPT. 5 hours of stress, headache, and suicidal ideation and I decided to take a few days off!  Flying from Cody to Denver for the first time. Hard not to chuckle a little at the stacks of carhart jackets and boots people are trying to squeeze into those little plastic bins. 

6am flight. That's all I have today.


  • Structure of Scientific Revolutions - Kuhn 
  • Still Alice 
  • A First Rate Madness: Uncovering the Links between Leadership and Mental Illness - Ghaemi 

On the Docket: 

  • All The Strange Hours - Loren Eiseley
  • Start with WHY - Sinek 
  • Phantoms in the Brain - Ramachandran
  • Battle Royale - Rowaiaru
  • Doctors: The Biography of Medicine - Nuland 
  • The Drunkard's Walk: How Randomness Rules Our Lives - Mlodinow 
  • Ready Player One - Cline 
  • How Doctors Think - Groopmman 
  • Look Me in the Eye: My Life with Aspergers - Robinson 
  • Second Opinions - Groopman 
  • One for the Money - Evanovich
  • Every Patient Tells a Story - Sanders 
  • The Fifth Discipline - Senge
  • Only What They Could Carry - ??
  • Under the Banner of Heaven - Krakauer
  • Hippocrates Shadow - Newman 
  • Consciousness Explained - Dennett 
  • Death of the Guilds - Krause 
  • Painful Yarns - Lorimer Moseley
  • The Best Practice - Kenney 
  • The Black Swan: Impact of Highly Improbable - Taleb 
  • Dan Brown Books -  The Da Vinci Code
  • Checklist Manifesto - Gawande 
  • Blink - Gladwell (re-read) 
  • One Step at a Time - Bliell 
  • Courage to Teach - Palmer
  • The Seven Laws of Magical Thinking.. - Hutson
  • Blindness - Jose Saramago
  • The Road - McCarthy
  • The Postman - David Brin
  • Oryx and Crake - Margaret Atwood
  • A Canticle for Leibowitz - Miller
  • Alas, Babylon - Frank
  • Z for Zachariah - O'Brien
  • Answer to the Question: What is Enlightenment? - Kant

Note to self (again)...

Rule #1: Keep Your Mouth Shut
Rule #2: You Reap What You Sow
Rule #3: No One Can Help Your or Be Helped By You if You Won't Help Yourself
Rule #4: You Do Not Know Everything
Rule #5: Pull When Possible
Rule #6: First Seek to Understand, Then to Be Understood
Rule #7: Do The Job, And Do It Well


Can Anybody Help Me?

Want a checkbox to write this sentence (a very small portion of a much larger project) and it's not working... Any ideas??? Much longer (non-functioning) version here: MvtDscROUGH

Does anyone reading know PAXScript?

function LowerFirst( InStr: String ): String;
begin result := LowerCase( Copy(Instr,1,1) ) + Copy(Instr,2,1000);
begin IF SF.GetFieldText('ExamMeasurement','ZZTRNSTYPE')='' THEN
   FOXTROT:='Patient is able to perform ' +

SF.AssignFieldText('ExamMeasurement','ZZTRNSNOTE',FOXTROT+NOTES); END; END;


In the near future...

A couple of years ago I totaled my 97 cadillac deville on the back end of a surburban sliding down a hill.  I bought a second ruined car, parted it out, and used parts/money from that to franken-car my deville back together.  The post showing a couple random pictures of taking the engine out is my all time highest viewed blog entry.  You can find it here:  http://www.denverlancaster.com/2009/06/its-like-legos-but-i-swear-lot-more.html

Fast forward several years.  Things I've learned to do on my car (in no order):

  • General maintenance/service:
    • Replace the brakes.
    • fuel filter
    • spark plugs, wires
    • air filter
    • oil change
    • anti-freeze change
    • rotate tires
    • serpentine belt replacement
  • Take apart and clean out the EGR valve
  • Replace fuel pressure regulator
  • Service brakes/rotors
  • remove fuel injectors/fuel rail
  • recharge A/C
  • remove/install coolant tank
  • remove/install AC Compressor
  • clean mass airflow sensor. 
  • remove/install water pump
  • remove/install radiator
  • remove/install alternator (ugh)
  • remove/install wind-shield wiper assembly
  • remove/install belt tensioner for serpentine belt
  • remove install belt tensioner & pulley system for water pump (other side of engine!)
  • remove/install manifold intake, service gaskets.
  • remove/install starter (under the manifold)
  • remove/install Blower Motor
  • replace serpentine belt with shorter belt to run car without broken AC compressor
I become more deadly with a ratchet and screwdriver every time something breaks on my car.  I still have a couple projects to do: 
  • remove/install rear suspension, replace with passive system
  • remove/install front bushings
  • there is a problem with the oxygen sensors to fix related to codes PCM p0171, p0151, p0154, p0174. 
  • HEADGASKET!!!!!!!! DAMN IT!    Looks like I'll be removing the engine again.  Maybe.  So far, it runs without overheating. 
Undiagnosed as of yet: 
  • Rough/long start when engine is cold. When taken up to running temp, and then allowed to sit for 40 minutes to an hour and a half with the engine off after being at running themperature, the car doesn't turn back on!!!!!!!!!! WTF?

So, if you're int he Cody, WY area, and feel like helping me pull a cadillac engine, let me know.  Alternatively, if you want to buy an engine, let me know.


Readings and Musings 8.31.12

Another collection of random things that have caught my attention.  In the future, I will try to put out this list of things a little more frequently.

The Best Argument in Favor of Open Access Science is All Of Them @Kevbonham  I shouldn't have to explain why this matters.  More information here: Open Access Publishing

Develop a Web Presence - tips and ideas for boosting your web presence, from social networking to blogging.  I'm still on google.  Maybe I should make a switch to boost my street cred. @adachis

Ridgeway & Silvernail 2012.  Innominate 3d Modeling: Biomechanically interesting, but clinically irrelevent.  @Dr_Ridge_DPT

Dr. Ridgeway was kind enough to supply with the full unedited prior to submission full text here.  Thanks!! 

Patients understand that they are in pain. Health care professionals like to try to explain why patients are in pain. But it's a spinning plate trick - to tell them what we know about pain without invalidating what they KNOW about how they feel, and how they believe it impacts them. I like the article What predicts outcome in non-operative treatments of chronic low back pain? A systematic review (Wessels et al. 2006) for this reason. Changes in cognitive and behavioral measures may be more predictive for treatment outcomes of chronic low back pain than physical measures. But more research needs to be done (click me). What I like about this review, and it ties back into other articles (like Mannion 2001), is that we shoud do more to address patients' beliefs about pain, fear avoidance, coping, and mood. I don't think these questions can be addressed without LISTENING to how patients feel, and what they understand about their pain. 

These info graphics are so cool:  Mobile Healthcare or validation for my interest in developing software.
More digital information: HIPAA Devices: 2 Myths Debunked, 1 Proven True from @WebPT.  Ipads are HIPAA compliant.  Cloud storage is safer than hiding money in your mattress.  Digital storatge is safer than paper storage. 

Forward Thinking PT Posts by @joebrence9.  The latest post is about the neuromatrix model of pain developed by Dr. Ronald Melzack.  The brain uses a vast integrative network of systems to interpet threats to the system contextually as pain. Cool stuff.  One of my major interests as a #physicaltherapist (when I get a license).


Extending Marketable Skills!

Baby steps.  I've already identified 3 or 4 resources now for coding my goal project.  A thanks to Paul Burton for showing off his code for using the android BT to connect to a L2CAP connection (wii hardware - think balance board).  The purpose, or goal of all of this, for me, is to learn to code and build OPEN SOURCE tools clinicians an use, and involve more CLINICIANS in the building process.   I'm learning.  And will blog about my learning, and share resources as much as I can.  Would love to find more, or involve more people.

This is going to be awesome.

3 weeks ago: Javascript (for posterity).  Then PAXScript (to modify EMR at the clinic where I work), and now I'm playing in Android!  By far the best learning resources I have found for all of these have been http://www.codeacademy.com and http://www.thenewboston.org.  Both supply learning tutorials for different programming tricks and have helped me learn exactly what an API is!  Very cool stuff.  Without further adieu, I present to you my bean counter! 

You can install this to your very own android phone by tapping here in your mobile browser. I wouldn't necessarily recommend it, but you can if you're curious.  I isn't harmful.  Will put an APK on your devices, run and install from there.

About my app:  I made a logo from some wrinkled paper, and old school project, and GIMP editor. I'm coding everything from the ground up using an application called Eclipse.  Immediately below is a short example of one of the manifest for my application called Bean Counter.   

At start up, there is a 5 second splash screen and a Hal9000 clip "Everything is going very well here."  So awesome.  After that it goes into a main app menu where you can select lots of options.  Right now there is only MainActivity (I'm working on thinking of a better name).  Selection takes you into a counter. counter++, counter--.  Simple right?  Sure it is.  


Marketable Skill Sets...

What I have managed to do: Take a page that has 350+ check boxes to quantify mobility assessment and rebuild it from the ground up in PAXscript into 5 functional-punch-in-the-numbers outcomes measures, AND 2 smart grids that step you through documenting the transfer if you were writing it out by hand (and faster, to boot). I've managed to build this on an iPad friendly screen. And for good measure, I'm programming a box to display a "narrative" of the documented findings so you don't have to do it yourself after you enter your data. BOOM. Marketable skill set.

My next project is gait analysis.

PT Complaint:   Unusable software.

Objective Findings:


More scripts.  Databases, Fields, and Subtables created.  Scripts written around those tables.

Behold: I call it Mobility Redux!  The auto-narrative isn't finished yet, but it will be.  Happy to give anyone using PTAdvantage.  I don't THINK that it is proprietary.  Would love ideas for the layout - as I am aesthetically-impaired.

Plan:  Finish narrative code, build gait analysis form.  


Rec Fem Causes Hip...


But that isn't what this post is about...  Our models for understanding pathology are too primitive to be meaningful.  The background of what I'm thinking:

This article is a perfect example of how remarkably complex human motion really is.  And all I can help taking from it is that after explaining the mechanism to 3 people now, all have fired back with "So, how is that functional?"  Without even giving a minute or two to try to think about a circumstance when something like that might actually be functional.

"This is what I've observed."  "It has to be this way because of the origin and insertion."

Besides the actual function and clinical relevance discussed in the article, I like to think more about how many other parts of everything I've learned act as functional oversimplifications.

These over-simplifications are the basis, for instance, for much of how we model and explain very complex evaluative tools.  I wrote this post a couple weeks ago, and have been thinking about it since then, with a little feedback from a mentor.  At the same time, not too soon after, a friend of mine (@RGWooderson) forwards a blogpost to me called "A Few Tests To Toss".  It is a great post that actually offered ANSWERS to some of the questions and things I've been thinking about.  A recommended read, for sure.

Now my purpose: 

The Low Back.  We try to model the mechanics of it, in all the spine's complexities.  And evaluate the "motion" people perform by merely touching and observing.  I'm not bashing touching and observing.  I think touch and observation are our greatest tools - just extremely inaccurate, or inconsistent at best.  And seem to fail to achieve proposed/described biomechanical influences. And in the end we are frustrated or confused - as a freaking profession! - about why we can't cure back pain.  Or why our outcomes for certain sub-populations aren't better than surgery. 

I'm not satisfied.  Not with the methods of evaluation I was taught in school - like SI movement, low back quadrant testing, and evaluating based on assumptions of biomechanics that don't hold true.  When I was learning it in school, and disagreed, I felt like I was out of the loop.  Like there was another lecture that I didn't get to hear. So WTF? Am I an idiot?  Arrogant?  Hopeless? 

Pain I understand - and trying to create a more meaningful picture with provocation testing (see "A Few Tests to Toss") makes sense to me, especially if it can be linked to treatments that are effective at reducing pain (are they?).  BUT trying to explain the mechanism of pain by assessing 1 - 2 mm of movement through centimeters of soft tissue doesn't just seem useless, it seems irresponsible.

One answer, as I was hoping to hear (homework: revisit hindsight bias) was outcomes.  We have got to critically analyze our treatments and their outcomes as a GROUP, and hastily discontinue treatments that don't yeild meaningful results - or as a practice we should be left behind.  Stop trying to explain the mechanism because it is very poorly understood.  Focus on what works, and be certain you are truly quantifying it. 

I started reading Doctors: A Biography of Medicine.  I haven't finished (thanks, self, for sucking at modalities and cardio/pulm).  There were two main schools of thought regarding medicine.  Both wanted to help patients.  One school of thought was Hippocrates, who, as the father of medicine, and, as I understand it from the book, discusses change in patient condition and patients getting better as the focus of his practice.  The other school of thought in Pergamon focused on pathology, and, ultimately, did not produce a father of medicine.  Galen was more like an uncle of medicine.  Brilliant, to be certain, but wrong frequently about anatomy and physiology.  Understanding of pathology, cell models, etc... was too primitive to be meaningful then, and in many cases today, too primitive to be meaningful now.   I like the clinical prediction rules as a starting point for treatment because, while ignoring the ever elusive question of "why are you in pain?"  it still offers solutions which have documented improvements compared to older methods of treatment. 

Rant over.

Jumping back on the cardiovascular/pulmonary and modalities studying for the NPTE bandwagon.  Thanks for reading. 



Thinking about Thinking

When I started PT school, I knew this is where it would take me.

Bad joke.  Let me explain.

Spent my whole life ignoring things like metacognition, because I preferred more discrete sciences. Love answers. Real answers.  But have, slowly, become enamored with social science and why we think and do the silly things we think and do, and how behaviors and thinking change over time.  Like a playground for my brain!  Errors in thinking... I make a great many errors.

What caught me about this, and why I decided to join the conversation on soma, is a book I've been reading about cognitive errors in the assumptions we create constructs of ourselves and the world around us.  The chapters on Hindsight bias and Confirmation bias have taken a lot of my brain power lately.  The book is "You are Not So Smart."

I suspect that some errors in clinical decision making come from the minds innate need to make sense of the world quickly to move on to the next stimulus.

Clinicians are trained (I just finished school, but hope never to finish training) to rely on "clinical decision making."  Human make decisions, which are subject to every kind of bias I've ever heard of.  Confirmation bias and hindsight bias (narrow spectrum, I know) work together to affirm our mistakes in thinking.  A perfect storm for error!  Hindsight works like this: an event/result/outcome happens.  In reflection, certain events stand out leading up to the incident.  You, being the reflective practitioner you were trained to be, try to construct patterns from randomness.  This is where it falls apart. Hindsight bias is "I knew it all along".  It's ignoring how you were wrong previously - taking from coincidence facts and ignoring other data to convince yourself you expected the outcome.   Confirmation bias is "I bought a honda, now all I see is hondas!  I must have bought a great car!"

The worst errors are of oversimplification (for the intent to do good!) of complex models to simpler ones.  This allows them to "see more" and explain more, and rationalize their own clinical decision making. To say "I knew that you would respond to ____" all along.  And a strong bias from then on to find evidence to SUPPORT instead of refute their newly constructed world view.  Confirmation bias is the reason my dad woke up every morning at 5AM to listen to Rush with his morning news before work (politics aside).  People look seek out things that agree with their world view to validate what they are already thinking.  Couple that with a strong hindsight bias and you have the recipe for a guru.  I will explain.  A guru isn't believable because they are good liars.  They whole heartedly believe that what they are telling you about piezoelectric effect when, in reality, most of what they are saying sounds very plausible because of a very plausible sounding model of electricity.  Or biomechanical models of spine pain. Or justification for ultrasound.  Craniosacral therapy.   I digress.

I am intrigued by the capacity of the brain to justify just about everything.  Including writing this post.

It's worth noting that I have not even passed my board exam yet.   Turns out I know a lot about neuro, musculoskeletal, and "other systems."  But less about the foundational sciences of the cardio/pulm system and next to nothing about modalities.  3 of those things are interesting to me.  2 of them bore me to tears.  One of them, as a category of intervention, is mostly crap (so far as my education is concerned, but more independent research on my part should be done). Care to guess which one it is?

Also, I could use a good recommendation for a "review cardio for the NPTE" book, if anyone has anything. Thanks.



Readings and Musings 8/6/12

Who's driving this thing?!
I get most of my news from twitter and google reader.  I LOVE taking in information from all over and trying to synthesize it into one coherent thought.  I've decided to start gathering these readings, tweeters, and resources on a more regular basis and share with you the things I thought were interesting.  Many will have to do with physical therapy.  Some will definitely not!  You've been warned.  Without further adieu, my first ever "Readings and Musings."   Love to hear your thoughts (if I haven't already).

Appledorn et al. 2012. A Randomized Controlled Trial on the Effectiveness of a Classification-Based System for Subacute and Chronic Low Back Pain  Current treatment based classification schemes do not improve outcomes in patients with subacute or chronic low back pain.

An Essay for Physical Therapists: Lets Move Forward...  An inspiration to move forward, and some issues that are very relevent to physical therapy right now.  There are some great discussion points about manual therapy, and the abuse of modalities.  Comments at the end of the article are worth reading too!

Mannion 2001.  Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance.  Three treatment groups, 1 outcome.  Strength changes through training for chronic low back pain did not appear improve outcomes.

One Word that Defines a Great Brand  Jeff Haden from Inc.com interviews Julia Allison about personal branding.  The interview and picture Julia paints of "personal branding" is organic.  You sell WHO you are, not just what you do.  It's about representing yourself through your values and connecting with clients.  As physical therapists, we seldom ask a patient "may I help you?"  We ask about their kids, grand kids, their dogs, grades at school, favorite sports teams, or the last book they read.  This article couldn't be more relevant to PT. 

Natural Cures?  "What medications are you taking?"  "I don't take any medications."  We might consider asking about supplements in addition, as I suspect (and I don't have a lot of evidence for this that isn't anecdotal, sorry) many patients don't consider the gingko they are taking to help their memory might also impact their balance (dizziness is a known side effect).  AMA strategies for health literacy.

Build Systems Not Overhead  Rhetorical talk about reducing overhead while improving quality.  Just some food for thought, I guess.

The Right Tools for Negotiating Your Salary – Part One: Your Value.   Part of a 3 part (so far?) blog roll about how to negotiate salaries if you're a new PT.  Interesting stat of the evening: this year, 12,738 new PT/PTAs will hit the streets looking for jobs. And we alllll want MONEY MONEY MONEY!  

Homework for the week:  Confirmation Bias and Hindsight Bias

People to follow:   @JayS_Tan, @MerylKevans, @Jerry_DurhamPT (unless you're a Giants fan). 


Meet Mable...

Mable was born on Dec. 27th. She is an English Mastiff. As of the end of July, she's 7 months old and nearing 70 lbs.  She enjoys long walks, drooling, having her belly scratched, and chewing on anything she can sink her little teeth into.  She is the cause of at least 30% of the anxiety in my life.  Ins't she cute? 

 Watch closely, you're going to see that chair again.

How bad could she be? 

She's just a puppy, right?


97 Cadillac Deville Alternator Removal

What goes in, must come out...

 I took the alternator out of my cadillac deville myself. I don't hate myself and I wasn't looking for a challenge. I was just broke. The instructions are as follows:

Negative battery cable
Serpentine belt.
Upper front bolt. 
Raise vehicle.
Front engine splash shield.
graphicRadiator support access panel.
 Loosen rear generator bracket from engine.
Remove top bolt.
Front lower bolt.
Lower rear bolt.
Upper rear bolt.
Duct from back of generator.
Electrical connections.
Battery output,
Heated windshield (if equipped).
Front generator/ A/C bracket.
Rotate generator and remove.

Rotate the generator and remove.  

Rotate the generator and remove.  

Okay.  Sure.  Rotate and... rotate and... wtf?!  So I toyed with it, and decided to make a video for posterity.  This is the alternator of a 1997 Cadillac Deville coming out of the bottom of the car.  No radiator removal required.  I apologize in advance for the swearing.

A few days later, my AC compressor clutch seized up.  Luckily, I had purchased the wrong length serpentine belt (when replacing the radiator) - which was just long enough to go through the engine without including the AC compressor.   Who's got 2 thumbs and not getting stuck in Midland, Tx?  This guy.