Rules Guiding Treatment: Excerpt from upcoming book entitled "Practical Biomechanics for the Podiatrist"

The following excerpt is from my upcoming book entitled "Practical Biomechanics for the Podiatrist" which should be released at the end of 2021 or summer 2022. I hope that there is wisdom in these words. 

And, as a patient, when it is obvious the rules being followed are not helping, speak up about a possible change of course or in some modality. 

More About Rules

Many rules in medicine are just guidelines. You need to learn that there are general rules of a profession or discipline and there are golden rules (some that you will need to create) that will guide your practice. A general rule is a guideline whereas a golden rule should not be broken, at least by you.  For example, the general rule is that lateral foot pain is from over supination and medial foot pain is from over pronation syndromes. The exceptions to this general rule are numerous like lateral ankle or subtalar joint impingement from over pronation or posterior tibial tendon strain from over supination. Therefore, general rules are guidelines with exceptions. An example of a golden rule is that if we help the patient create a 0-2 pain level for all phases of rehabilitation and all activities the patient will be given the opportunity to get better.  Learn the general rules of your profession, but create your own golden rules. Write them down, say them out loud, and to others, and do not vary. The next few paragraphs include a couple of my many golden rules that help me practice, and as a podiatrist you may agree or have your own golden rules. 

      Golden Rule: All bone pain can be caused by poor bone health. Seems very simple written that way. A patient presented with severe bone pain causing shin pain for 2 years. I was the 8th doctor he consulted. He was 27 years old. At the first visit, with none of his previous records yet to go on, I applied my golden rule due to his palpable shin bone pain and ordered a bone density test. It came back that he had severe osteoporosis with the bones of an 83 year old. He is gradually improving with the help of an endocrinologist. This had been missed at a major university hospital.

      Golden Rule: Medial meniscal pain is either helped with valgus wedges or varus wedges. It took me a while to learn this one practicing in an orthopedic clinic. The general rule is for valgus wedges to be used with medial meniscal pain to attempt to open up the medial knee joint line. If that did not work, meniscal surgery was done. But, I remembered that Dr. Root had taught that pronation caused tibial inversion which can crowd the medial compartment. When patients did not respond to valgus wedging, I just flipped them over to give them a varus wedge. It proved to be around 45% of the patients responded to varus wedging and 45% of the patients responded to valgus wedging, with 10% still needing imminent surgery. In the long run, some of those patients did require surgery but some 40 years later are still coming in for their wedges to be made.

      Golden Rule: Low Back Pain that feels worse with walking or standing or moving may be helped with foot biomechanical corrections. A 24 year old patient with golf related low back pain was referred to me after 2 years of physical therapy, micro-disc surgery, and then 2 years of chiropractic treatments. He experienced no pain sitting or lying, only walking and after one hole of golf (many attempts in those 4 years). When I performed my initial cursory gait evaluation, I noticed a lean to one side (many causes of that), and he commented I was the first person to watch him walk in 4 years. Osteopathic evaluation noted a possible ½ inch short leg and some foot pronation. Due to the length of his disability, immediate AP Pelvic Standing X Rays in Normal Stance Barefoot were taken documenting 7/8th inch short leg. Within months after correcting all his shoes, he was back playing full rounds of golf with no problem. We never got around to correcting the pronation part of the picture. Years later I met his dad who informed me that he was doing great, and only asked if I felt the back surgery had been necessary. Oh well for my $200 treatment!

      Golden Rule: Always Treat all 3 causes of pain in patients presenting in pain (this is a tie in to my last blog post). Those are mechanical causes and their treatments, inflammatory causes and their treatments, and neuropathic causes and their treatments. A problem can be caused by one source, but need to be treated by all three. A problem can start mechanical, and then have the inflammation and nerve hypersensitivity develop days and weeks or months afterwards. I find that body reactions to a problem are like a bell shaped curve with an average reaction and people on either side of average. It does not matter what response you are talking about (swelling, pain level, scarring, nerve hypersensitivity, muscle atrophy, etc.) there are those that hardly have any reaction, or a more normal reaction, or an exaggerated reaction. The wonders of the human body are on full display at times. Almost daily I see patients for 2nd opinions with heel pain treated with orthotic devices that are not improving. The orthotic devices are typically well constructed, but create too much heel pressure. The general rule with heel pain and orthotic devices is that the devices should soften the heel and transfer the weight to the arch. It is typically easy for me to adjust their current insert. Yet this is only the mechanical treatment of the heel pain, with the inflammatory and nerve aspects of treatment normally needing more options. It can be tricky since what helps inflammation does not normally help nerves, and vice versa. Nerves hate ice, love heat. Inflammation loves ice and heat can make them worse. Sometimes finding out how a patient responds to ice or heat can help guide the treatment of what is most important at that time.

Injured or Treating Someone Injured: Fight Inertia and Get Going

Golden Rule of Foot: When injured in one sport, find another one or two to keep healthy. 

     These Golden Rules which are all over this blog are rules never to be broken. However, this article speaks of how we become so addicted to one method of exercise, that when we can not do that exercise, we also have the inability to do something else. Inertia wins (and in this case it is psychological inertia). As health care providers, it is a good reminder as we talk to our athletes, that we help them understand the significance of cross training. Do not say "I think you should do something else for awhile". Say "we really need you to spend 30 minutes every other day on a bike and 30 minutes on the elliptical. Also, on your off days start hitting the weight room for your core, upper extremity and stretching." Be more proactice!! Your athletes will rehab better.

Golden Rule of Foot: When injured in one sport, start cross training the next day. 

https://journals.lww.com/acsm-msse/Abstract/publishahead/Injured_Runners_Do_Not_Replace_Lost_Running_Time.96421.aspx

Golden Rules of Foot: Sacred Parts of any Practice of Medicine

                                     Golden Rules of Foot

There are rules that govern everything, and medicine is no exception. There are very special rules, which I call the “Golden Rules of Foot” that apply to all aspects of my practice of podiatry. I live by these rules. They are sacred to me. Where some rules are made to be broken, these rules are close to unbreakable. When I make a logical decision, based on much thought and consideration, to break one of these rules, I get mud on my face. These are rules with little or no exceptions whereas most general rules have many exceptions. When I practice the science of podiatry, the rules I was taught, or read in books, or hear at seminars, have many exceptions. This is the art of medicine. The Golden Rules of Foot are part-science and part-art. When they are learned and practiced, healing occurs. When they are broken, in my rush through the day, I typically regret it.

     Every health care provider will actually have their own Golden Rules, formed by years of their unique personalities, observations, and patient experiences. But, Golden Rules can be learned instantly, when we are open to learning (our life long task!). Golden Rules typically do not take a long time to become embedded because they speak to our souls as true from the start.

Golden Rule of Foot: Whereas the human spirit is very sacred, the golden rules of foot are also sacred.

                                         The Balance between Art and Science in Medicine

     It is not the purpose of this posting to go over every rule, but I want to expose the reader to them

in some way. I challenge the health care provider to come up with 50 or so of their own Golden 

Rules of Foot. Again, there are rules and there are Golden Rules, and it is important to make the 

distinction of what is unbreakable. Golden Rules should be unbreakable. Here are 56 examples of 

my Golden Rules.

Some of the Golden Rules for Rehabilitation:

Golden Rule of Foot: Begin strengthening the area the moment you are injured.
Golden Rule of Foot: In overuse injuries, we injure the weakest link in the chain. It is our job
                                   to find out why it is the weak link.
Golden Rule of Foot: Most overuse injuries have 3 causes to look for (at least).
Golden Rule of Foot: The foot is the foundation of the body, and if off by a little, can cause injuries to occur. Always look in treatment to make the body more stable starting at the foot.

Golden Rule of Foot: Listen to your body. It will not lie to you.

Golden Rule of Foot: Never push through pain that begins in a workout, progressively gets worse, and produces limping.

Golden Rule of Foot: Never mask pain with pre-activity drugs, including ibuprofen, aspirin, etc.

Golden Rule of Foot: About 80% of healing occurs in 20% of the overall time, with the remaining 20% taking 80% of the total time.

Golden Rule of Foot: Good pain normally dwells in the 0 to 2 pain level (scale 0 to 10).
Golden Rule of Foot: Obtain 0-2 pain levels when treating injuries as soon as possible with whatever means possible and maintain that level through the rehabilitation of the injury. 

Golden Rule of Foot: When 80% of the symptoms are reduced, and normal walking occurs without limping, a return to an activity regimen can be initiated.

Golden Rule of Foot: Treat neuroma/nerve pain aggressively, or it will decide to stay around.
                                    Nerves can cause their own pain, making the original problem worse.

Golden Rule of Foot: Place yourself back into the immobilization phase when you have consistent flare-ups or are getting worse.

Golden Rule of Foot: Allow time for rehabilitation to succeed or to fail, so you can possibly avoid unnecessary surgery or you will know you need surgery.

Golden Rule of Foot: If you are advised on elective surgery, get a second independent opinion, and do not tell the second doctor what the first doctor wanted to do. You want an independent consultation.

Golden Rule of Foot: When rehabilitating an injury, always have a Plan B.

Golden Rule of Foot: If there is swelling or internal joint stiffness, you must work on it daily.

Golden Rule of Foot: Our feet deserve our utmost concern, respect, and care.

Golden Rule of Foot: Do not make treatments more complex than they need to be.

Golden Rule of Foot: If you can find a stretch that makes the painful area feel better, and you are halfway home to full rehabilitation.

Golden Rule of Foot: Keep It Simple Stupid in your treatments whenever possible.

Golden Rule of Foot: In restoring full function, there are many effective treatments available, so experiment or get other opinions.

Golden Rule of Foot: For every day in a cast or boot, it takes two days to get back to normal.
Golden Rule of Foot: We lose 1% of muscle strength daily with an injury, and only gain back 1/4% daily as we rehabilitate.

Golden Rule of Foot: Never get a cortisone shot when you are not sure it is needed, and if other good treatments are available.
Golden Rule of Foot: Never get a long acting cortisone shot into or near a tendon.
Golden Rule of Foot: Submersion is the best way to apply ice or heat.

Some of the Golden Rules for Diagnosis:

Golden Rule of Foot: Treat the patient, not the test.

Golden Rule of Foot: When taking X-rays of the feet, take them standing whenever possible to show alignment issues.
Golden Rule of Foot: An x-ray may not show a stress fracture in the first 2 weeks of an injury, or ever for that matter.
Golden Rule of Foot: Always think that pain can have 3 sources: Mechanical, Inflammatory, and/or Neurological.

Golden Rule of Foot: When the pain is superficial and not responding, look for a deeper problem.

Golden Rule of Foot: Watching a patient walk or run can be crucial in finding the cause of their problem(s).

Golden Rule of Foot: If an injury comes on acutely, and there is noticeable swelling in the area, the diagnosis is stress fracture until proven otherwise.

  

Golden Rules for Running

Golden Rule of Foot: If you cannot run 5 miles, see if you can run 1 mile, or even 1 minute.

Golden Rule of Foot: It is better to run one second than not at all during the rehabilitation process so you can tell your providers your  activity level accurately.

Golden Rule of Foot: When you can walk 30 minutes at a good pace without pain and without limping after an injury for three straight days, then you are ready to start a walk/run program.
Golden Rule of Foot: Training should allow of periods of recovery (typically 36 hours)

Golden Rule of Foot: Do not change shoes within six weeks of the start of a marathon.

Golden Rule of Foot: Do not change shoe type, running style, or orthotic design when you are increasing your activity levels weekly.
Golden Rule of Foot: Alternation is Important in Training with various distances, surfaces, shoes, and speeds.

Golden Rules for Ballet

Golden Rule of Foot: In treating a ballet dancer, it is important to review their technique.
Golden Rule of Foot: In treating ballet dancers, you must investigate the activities that they 
                                   do when not dancing also. 

Golden Rule of Foot: En pointe should begin when the dancer is skeletally mature, 12-13 years old, has good technique, and a minimum of three years of ballet experience.

Golden Rules for Home Treatments

Golden Rule of Foot: When in doubt to heat or ice, use ice.

Golden Rule of Foot: After an injury, try to attain a pain-free environment as soon as possible (0-2 pain levels).
Golden Rule of Foot: Athletes must understand Good and Bad pain.
Golden Rule of Foot: Strengthening Programs should be done in the evening within two 
                                   hours of bed to allow the area to rest after fatigued. 
Golden Rule of Foot: Stretching should never hurt, and if needed, should be done 3 times a day. 

Golden Rules for Short Leg Treatment

Golden Rule of Foot: With lift therapy, start low and go slow.

Golden Rule of Foot: Keep lifts and orthotic devices separate.
Golden Rule of Foot: Low Back and Hip Pain produces by walking is Short Leg Syndrome 
                                   until proven otherwise.

Golden Rules for Orthotic Therapy

Golden Rule of Foot: When designing or wearing orthotic devices for plantar fasciitis, the patient must feel the weight is being transferred from the painful heel area into the arch, and the patient must feel that the heel area is being suspended or cushioned. Without these two factors occurring, the orthotic devices will not be as helpful as possible.

Golden Rule of Foot: When dispensing orthotic devices (or receiving them), there should never be any pain.

Golden Rule of Foot: When getting used to new orthotic devices, always blame any new

pains on the new devices.

            Golden Rule of Foot: Never introduce new orthotics into an athlete increasing their mileage (like in marathon training). This should be during maintenance running periods.  

Golden Rule for Running Shoes

Golden Rule of Foot: If pain is produced by one pair of shoes but not the other, stay in the pain-free pair.

Golden Rule of Foot: Look for Asymmetrical Wear Patterns as a sign of something wrong.

This above was an excerpt from my book: Secrets to Keep Moving.

Golden Rule of Foot #1: Treat Every Patient with the Same Respect, Kindness, Care and Concern

     I have all of these Golden Rules I try (many times fail) to follow in my life. I love these rules of nature, of life, of love, of soul. My Golden Rules are sacred to me and I am miserable (or at least uncomfortable) when I break them. They extend into every facet of my life, so why not into my version of the practice of medicine. It is called the practice of medicine may I remind you all out there. I am practicing an art with my Golden Rules. Not a perfect art but full of the reasons that the word HEART has ART in it. These rules are sometimes taught in the medical schools, but mainly taught in the school of life. They really have no order, but society demands some bullet points, some indexing. Every person has their own golden rules, so think of your own as you reflect on mine. One of the keys is not to compartmentalize them, thus using drastically different rules in apparently different environments--like work versus home. As I meander through them with various posts, I hope you will stop for just a second reflecting on your own similiar golden rules.

Golden Rule of Foot #1: Treat every patient with the same respect, kindness, care, and concern.

     This is #1 because it is at the very soul of medicine. If you think of your relationships with others you realize this is impossible at first glance. We are only human. We like some people more than others. Those we like we tend to treat better. Those we like better tend to get more respect, more kindness, more care, and more concern. But, we must continue to work towards this truly Golden Rule. It is sacred. It will bring out all of the values we hold true. As you try to follow this rule with someone you really don't like, humility and emptying of self must surface. A health care provider with humility, an interesting concept!! Can it be a reality? Trying to follow this rule will allow humility to begin, and true caring to unfold. Try, fail, try again, and keep trying throughout your life.

Golden Rule of Foot: Keep It Simple Stupid

Golden Rule of Foot: Keep It Simple Stupid

     Yes, the famous KISS principle applies here as in most aspects of life. So, it is a great start to the Golden Rules of Foot that podiatrists live by. For every treatment plan, there are simpler and more complex modalities. Patients can help you decide if you go for the big guns or start slowly. I make mistakes all the time being too simple when more complexity is needed, and too complex when simple will do. So, I allow my patients a vital role as we discuss options. It is the nature of a sports medicine practice anyway for the doctor/therapist and patient to team up to work together on the problem(s) at hand.

     One of my patients today just injured her posterior tibial tendon. Because of many factors, including the fact that she ruptured the other posterior tibial tendon 15 years ago, I immediately ordered an MRI to know what direction to go towards. This would be considered a more complex approach, instead of a more simple xray, with course of icing, anti-inflammatory medication, and ankle brace. But, the seriousness of possible missing a tear and immediately treatment thus I could not take a chance. The more one uses an MRI you see when and where it really makes a difference. No KISS Principle today.

     One of my new patients today was in for a second opinion regarding big toe joint surgery. Very serious stuff, but her conservative care was very lacking, and the surgery suggested very complex with joint replacement. I started her icing 3 times daily, spica taping to hold the joint still, Cluffy wedge to place weight on the first toe, and dancer's pads to further off weight the big toe joint. Simple stuff to start for a serious problem. She is to call or email in a month and also send me her MRI done 6 months ago. Here I am starting with the KISS principle since it seems helpful and direct.

     One of the interesting factoids I have learned is that complex is exciting, interesting, and seemingly professional to most doctors, therapists, and doctors. They expect treatments to be something the patient do not do on their own. Add a laser into the discussion and everyone gets excited. Medical schools and seminars emphasize complex treatments and testing. And this is how the KISS Principle gets ignored, violated, battered, and destroyed daily in most medical practices. Students who rotate occasionally through our office seem bored with simple solutions and definitely are not taught this stuff. I rarely see a bunion patient with toe separators by their podiatrist as an example.

     I am internationally known for my orthotic designs, yet I use OTC orthotics routinely when KISS applies. I always prefer icing and contrasts to oral medications or injections. If a patient said that they would rather have surgery than to ice 2 times a day for the rest of their life, I would have a vigorous discussion of why that may not be prudent. The KISS principle can be boring, time consuming, and non-flashy, but 90% of the chronic pain patients I see have a very inadequate KISS based conservative program of treatment when I first see them. These are patients that have seen up to a dozen of health care providers. I also give credit for this dilemma to the patients for not following through on simple treatments, or implying to the health care provider that it sounds too simple (the provider hears that as an attack that they are "simple minded.") How often are simple treatments ended because they only gave 20% pain relief when 5 simple treatments additively could give 100% pain relief.

     When you are going through treatments, find what works even partially, and stick to them for 2 months longer than you need to due to pain. Make your treatments additive (One from Column A, One from Column B, etc). Add complexity when needed, but if the treatment complexity seems more than the seriousness of the injury, ask questions. And if the treatment simplicity seems not enough for the seriousness of the problem, ask more questions. I sure hope this thought process is helpful. Dr Blake
   
     

Golden Rule of Foot: Pushing Through Pain May Build Character, But It Also May Cause Permanent Injury

 Blogging on Wednesday is Golden Rule of Foot

      There is always some pain with athletic endeavors. But, one of my earlier Golden Rules of Foot: Follow the 3 day rule, If pain continues for 3 days without changing for the better, do something about it. I have spent 30 plus years in practice telling patients about my 3 day rule. Does anyone listen? Do I even listen?

      Yesterday I had my second patient need big toe joint fusion. It is supposedly the best operation for severe degenerative joint disease of the big toe joint, but how did the patient get there? How did the joint get so bad that she was the 2nd person ever to have such a drastic procedure? Did she push through pain daily? If she saw me 10 years ago, could the joint been saved?

     Probably the top post I refer my patients to daily regards understanding what is Good pain and what is Bad Pain. Here is the link.

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

     Life is too complicated to run to the doctor with every ache or pain, plus you may not get the best advice, or at least advice you want to hear. So, developing a better sense of when pain is harmful will definitely help us continue walking into our later years. Another Golden Rule of Foot: Listen to your Body. In sports medicine, this connects the patient to the treatment. The patient must be an active participant in the healing process. They must listen to the major and sometimes subtle trembling within the body. My wife Pat is one of the most astute listeners. I am in my head too much.

     So, with all my rambling, the Golden Rule of Foot I am focusing on today is Pushing Through Pain May Build Character, But It Can Also Cause Permanent Damage. Patients with high goals, I mean high, can be at risk of damaging their bodies permanently since the goal is so important. Patients with high pain thresholds may just not sense when they are hurting themselves. But even normal people, can do very stupid things and cause irreversible damage to important structures. Since athletics hurt, I must be hurting like everyone else. Who can they compare it to?

     From the Good Pain vs Bad Pain discussion, we learn that bad pain is definitely sharp and causes us to limp or favor the injury. In actuality, anything over level 2 pain (due to variations in pain thresholds) for a sustained period of time, can cause damage. It all boils down to that pain is our friend. Pain is normally telling us that something is wrong and we must fix it. We must reset the body back to homeostasis. A painful body must be taken seriously.

     I remember when I was first in practice that a patient in a lot of pain came into the office for treatment. Once he found out that the source of the pain was not serious, he said thank you and left. He never wanted treatment. He did not have time for that. But, he would of, if the problem he was dealing with was serious. He needed me to tell him to that all was fine, things were a little out of whack, but if he listened to his body he could be fine again without permanent damage. I was too new in practice to realize how much I helped him that day. I remember being amazed that he did not want any of the 10 treatments I had for him to try.

     So, if you have been in pain that is not improving for more than 3 days, if your pain level stays above 3 out of 10 when you are active, if you have sharp pain or limp, consider seeing someone to make sure you are at least not causing any permanent damage.

    

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.

Golden Rule of Foot #2: Listen to the Patients, and then Listen Some More

     It is amazing what we think we hear. It is amazing what patients can tell us if we listen to them, and that normally takes some time. Patients should always ask: Are my health care providers listening to what I are saying? It requires time, and a desire to listen, even when you think you already know the answer. For, when you listen, you will hear more richness than mere answers to questions.

     I work in a clinic, and a very nice one at that. My wife and I have long decided that this is the best place for me until I retire. I am very slow and do not care much for the details. Being an independent contractor, I can see one to 4 patients per hour (my choice). What pays more? Your guess will probably be right, but I tend to chose the one patient. The world says that this is sad. Reality of bill paying says that this is sad. Many times I doubt my dedication to my family. I should be bringing home more income. But, I have never ever doubted my dedication to my patients. And I give them the time they need, or I need, or we both need. But, time is all we got to give another human being. In that time, things can happen. Wonderful things.

     I saw a patient Erica today. Probably spent over 1 hour with her. She had seen 2 other practitioners before me who missed the diagnosis of her broken heel bone. It was a quite obvious diagnosis. Why did they miss it? I bet time restraints. Too much on their plates. I was not smart, no need to brag, needed an MRI for the diagnosis. It all just took time. Probably my lack of desire to be a good provider for my family actually helped me be a good doctor to Erica. The world tells me this is sad, but my heart is happy. I helped Erica today, and Joseph, and Cheryl, and several others. This is why I told myself in high school I wanted to be a doctor. I wanted to help others. And it starts with Listening.