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Tuesday, July 5, 2011

Golden Rule of Foot #3: Think Outside The Box

     When treating patients for a perceived diagnosis (like plantar fasciitis or Morton's neuromas), there are very standard protocols that can help. Doctors and therapists learn these in school and use them diligently on patients. But protocols in actuality are built on generalizations. General rules can become generalizations when they are only 50% (give or take a few percentage points) accurate. It is amazing how emotionally tied we are to these generalizations. They are our rock of stability in the very unstable world of medicine. We need these to function. Or do we?

     I have been very blessed at working in a multi-disciplinary practice. We have general podiatists (like me and Dr Denton), surgical podiatrists, general MDs, surgical MDs, general physical therapists, and specialist physical therapists (ie Dancemedicine approach or manual only approach). Being exposed to this variety of health care providers has given me an understanding that protocols are mere guidelines. My protocol may not be another's protocol. Sometimes we will end up in the same place, sometimes not.

     So I go along and apply my protocols and see how the patient responds. If they are doing well then great, and we keep moving along on my protocol of apparent success. And at anytime, they may not be doing so great, and I may have to change to a different approach (someone else' protocol). The next Golden Rule of Foot is about perfecting your skills, but for how let's focus on Thinking Outside the Box.

     I have a Box of Knowledge of Medicine that I practice with trying to help patients. For most part, I am comfortable with that knowledge. It has become part of my skillset. When a patient presents with a problem, I immediately judge if their problem and my box are compatible. As I learn about the Boxes of other practitioners, I may refer that patient immediately to another, or at least keep that possibility in mind. If the compatibility is strong, I may be able to stay inside my box during the entire treatment course. If the compatibility is less than strong, my box may be inadequate, and the treatment may need to go another direction.

     So, Thinking Outside The Box is really 2 distinct issues acting on the universe at the same time. A health care provider is called to Think Outside The Box when the patient is not responding to a simple protocol, perhaps in reality based on a weak generalization. Recognizing that the protocol is not working, the practitioner should change courses. Sounds easy, but protocols can become part of your mantra, part of your soul. This is why for some practitioners this aspect of changing course is difficult, even in the situation of an unresponsive patient.

    The second issue at work here is not the protocol, but the Box itself for that practitioner. I love when Gene Hackman put the dot on the basketball in "Hoosiers" as the Box for the players, the center ring of the ball (circumference) was the coach's Box, and the volume of the entire basketball was the true Box of Knowledge needed. Sometimes I feel like I know 1/4 the volume of that ball, and sometimes only the circumference. If, on good days, I only know 1/4 of all the possibilities, Thinking Outside The Box means that I recognize that someone else may know the answer.

     There is a certain peace in medicine knowing that you know a part of a big Box of Knowledge. I think I can do a good job, sometimes great job, practicing in my Box of Knowledge and occasionally, when needed, thinking Outside That Box. Whether that means scraping one protocol for another, or being downright ingenious with my own template for a specific patient, or allowing myself the peace of referring to another whose Box is different than mine. True learning will occur in these situations as your Box will become alittle bigger.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.