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The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Sarah Macaraeg talking about clinical excellence in physical therapy.
[00:00:12] Dr. Macaraeg: In our patients, very often, their pain is dismissed by some healthcare providers. You know, these clinicians have rushed schedules or whether it's implicit bias or kind of lack of this holistic mindset when they interact with some specialists. So, you know, I know you teach this a lot with your mentees of like listening and acknowledgment of a patient's experience can really go a long way.
[00:00:45] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence. On this podcast, we speak to patients and doctors, and other healthcare workers about all aspects of excellence in clinical medicine. I'm Adam Cifu and today I'm joined by Sarah Macaraeg.
Sarah is a physical therapist working at UChicago Medicine. She is a Board-certified clinical specialist in orthopedics and women's health physical therapy, as well as a fellow of the American Academy of Orthopedic Manual Physical Therapists. She is on the faculty for the orthopedic physical therapy residency and fellowship programs at the University of Chicago Medicine.
Sarah primarily treats the orthopedic and pelvic health populations. She finds fulfillment working with patients of high complexity and those who experience persistent pain. Over the last 10 years, Sarah and I have collaborated in caring for many patients, and full disclosure, my entire family has benefited from her clinical skills.
Sarah, thanks so much for joining me.
[00:01:48] Dr. Macaraeg: Thank you so much for having me.
[00:01:49] Dr. Cifu: So first, just tell me a little bit about your route into physical therapy. Was this like an early goal that you decided when you were, you know, four years old that this is what you wanted to do? Or it was something you kind of came to during school or experiences or...?
[00:02:03] Dr. Macaraeg: Yeah, more or less, I would say was very lucky. My grandfather, he was an orthopedic assistant in World War II. And so from a very young age, I was involved heavily in sports and, you know, sprained ankle here, jammed thumb there. He was there wrapping me and teaching me, you know, little things here and there. And that kind of sparked my interest with getting in tune with how the body works and how joints are and how the body can heal itself. So when I was a student in high school, I was one of those very insane children that was like, "I'm going to figure out what I'm going to do with the rest of my life."
So there was a student athletic training program at my high school. So that's where I got involved with basically being a glorified water girl, but you know, wrapping ankles and putting ice on kids, and hooking them up to Easton, which back then was not illegal like it is today, but at least got me interested in the rehabilitation side of medicine. So I luckily went to a school where I could get admitted as a direct physical therapy student as a freshman. And it just helped solidify that career path. I went to a wonderful school that had a very holistic approach to treating patients and luckily ended up still loving it. So here I am 12 years later still treating, and that's kind of how we got into it.
[00:03:24] Dr. Cifu: Did you feel–? I mean, it sounds like you are sort of unique in that you almost had so much training before you got to training. That can be, you know, a blessing and a curse for some people, because often you have to unlearn things before you learn new things. Was that the case for you?
[00:03:41] Dr. Macaraeg: For sure. Definitely in some ways. I had spent a lot of time in undergraduate working as a rehab tech in a PT clinic, which is super common for a lot of PT students.
And there's a wide variety of treatment approaches and plans. So definitely learning some things from that aspect and then getting into school and being like, "Was that the best way to go about things?" So there was some granted minute at that point but it did at least help have a better awareness of what is anatomy and better appreciate an application of that by the time I had gotten to school.
[00:04:16] Dr. Cifu: And it's probably nice to have the sort of clinical experience before you get the almost more, I don't know, academic or evidence-based teaching, you know, to be able to really bring those together as you learn.
[00:04:29] Dr. Macaraeg: Exactly. Yeah.
[00:04:30] Dr. Cifu: So whenever I get to talk about clinical practice with sort of, you know, non-physician clinical colleagues, I'm always interested in how much our jobs are the same and how they differ. I always think physical therapy and primary care, internal medicine share a ton, right? We have a lot of extended relationships. There's kind of diagnostic and therapeutic interventions, which we can– There are things that we can fix and there are a lot of things that we can't fix and just have to sort of manage. There's the need to work with, you know, doctors and consultants and things like that. So just thinking a little bit about that, like, what do you see as similarities and what do you see as kind of the biggest differences you think?
[00:05:13] Dr. Macaraeg: I really appreciate this insight and thank you for bringing that up. Sometimes it does feel isolating to hear patient stories and feel limited with what we can do as physical therapists.
So I think in terms of similarities to start off with, I think we both have the opportunity of time, which you magnificently brought up. You know, we– Granted, you have more time through the lifespan, whereas we have time within a short period, but we're able to adjust our interventions based off their symptoms when they come and see us week after week.
And it's through this trial and error that we can really hone in on the issue that we're trying to resolve. So, you know, not only do we learn more about what brings them into PT, but also who are they as a person? Where do they live? What is their support system like? Do they have any environmental insecurities?
But then we also learn fun things, like what do you do on the weekends? What's your zodiac sign? You know, what shows are you watching? But you know, that all helps us gain rapport with our patients. And then they usually feel more comfortable disclosing things that they might not have had the opportunities to disclose with some of their other physicians.
So, you know, another thing too, similar to primary care, internal med, we're able to have like a systems knowledge and able to bring that into place and add to the pieces of the puzzle to advocate for our patients to get these referrals. So we have the true privilege of listening to our patients and our patients, very often their pain is dismissed by some healthcare providers and they're– You know, these clinicians have rushed schedules or whether it's implicit bias or kind of lack of this holistic mindset when they interact with some specialists. So, you know, I know you teach this a lot with your mentees of, like, listening and acknowledgment of a patient's experience can really go a long way.
[00:07:06] Dr. Cifu: It's so interesting. Let me cut in because I had not thought of this until you mentioned it, but it's something that I've been jealous of, when I'm a patient in physical therapy, is that as a clinician, and we've talked about this on the podcast, I always feel like, God, it's so important to, you know, get to know people. And I love that about my job, but often I feel like, uh, it's an extra. And, you know, maybe that makes the person happier seeing me, more comfortable seeing me, but does it really improve outcomes, you know? What I often find in physical therapy sessions when I've been the patient is that that sort of distracting banter, you know, is like an important part of the therapy because, you know, it distracts me, it has me not thinking about, you know, what the injury is or what the pain is. And it ends up being something that draws me back almost, which is I guess maybe the benefit of it in primary care as well.
[00:08:06] Dr. Macaraeg: Yeah, and I think too sometimes like even with that unintentional banter, you get more pieces of information about somebody.
[00:08:15] Dr. Cifu: Absolutely.
[00:08:16] Dr. Macaraeg: Like, "Oh, I didn't know you also like to do that. That totally makes sense in regards to this injury." Or, "Oh, you sleep like that? Well, let's talk about that." You know, and it could really fill in some of the blanks that, you know, give you a better picture.
[00:08:30] Dr. Cifu: Right. And maybe opens up the goals of the therapy more when it's, "Huh, this is something that's important in your life, which I wouldn't have known about, you know, we should concentrate on getting you back to that because that's what's going to make you satisfied."
[00:08:43] Dr. Macaraeg: Exactly. And that's something that I tell my students time and time again, like you might not be the smartest therapist on the team, but if you can listen and hear what your patients are saying, you're going to get that patient better than the person who can quote an article.
[00:08:59] Dr. Cifu: Got it. You were going to say something else. I cut you off.
[00:09:02] Dr. Macaraeg: Oh no, it's quite all right. All in all, just to sum up our similarities, I think our access to med– Our patients' access– Let me rephrase that. Our patients' access to medicine is very similar to PT and to primary care. It's so much easier to get in to see us and have that consistency as opposed to a specialist.
So, you know, I had mentioned we have more time with a patient in the short term, whereas you have more time with a patient across their lifespan.
[00:09:31] Dr. Cifu: This is a question maybe for a little bit of reflecting on my practice and seeing I don't know, what do you think of this? May have been– It may have been an answer to a question I was going to ask later.
I have always valued the diagnostic skills of physical therapy, I think in general, and specifically, the people who I've always gotten to work with now for the very reason is that most of my, you know, diagnostic interventions with a patient, especially in the physical exam, are two to three minutes at best.
And I recognize that, you know, in early sessions, you know, you're often spending 20-30 minutes with the person, really with hands-on manipulating them. And I feel like getting calls from the therapist about what's actually going on with the patient is very helpful. Is that a comfortable thing for you guys in the kind of, I don't know, healthcare hierarchy, for lack of a better word?
[00:10:29] Dr. Macaraeg: No, it's a very good point of, you know, we– Again, going back to that point of time, like we have 30 to 60 minutes at times with the patient to do that physical exam. And I've treated other primary care physicians in the past too. And that's one thing they've mentioned of, they're now retired, but saying, "The art of the physical exam is gone."
But you know, like that's our bread and butter, those are the tools that we have, are our hands. Whereas you have different tools at hand. And I'm going to bring that up when we talk about differences, but to answer this question in terms of, you know, that hierarchy, I think PTs in general, generally feel more confident with our physical exam because we're able to be more thorough, because we have that different specific understanding of the musculoskeletal system that we don't necessarily expect other healthcare professionals to have.
So to some degree, it is kind of nice to be able to say, "Hey, this is what I think," but there is a certain degree of, "But I don't want to step on your toes." It's like, "Hey, this is what I think. What do you think, too?" Just to make sure that obviously, we're all collegial and on the same page, but it is an opportunity to at least give feedback, and generally speaking, most physicians are like, "Great, I love what you're able to see. Let's try and work out a plan."
[00:11:50] Dr. Cifu: Good. Those physicians you talked about, did they retire because you weren't able to cure their pain?
[00:11:57] Dr. Macaraeg: Correct. No.
[00:11:58] Dr. Cifu: And then you mentioned differences. Like, where do we part ways? Obviously, we do very different things, and although a lot of the relationship is the same, what are things that stick out?
[00:12:11] Dr. Macaraeg: Yeah, I think kind of what I was foreshadowing was we're pretty limited in terms of medical diagnostic tools. You know, we are an– Essentially, nationally, the degree has moved to a doctoral degree, which is great to allow us to have more direct access in most states but the disadvantage to that is we have a limit on what we can quote, 'diagnose' a patient with.
So, you know, even simple things like ordering plain film X-rays, you know, we're not even asking for an MRI, but you know, doing something like that, or even being able to prescribe some specific to PT, you know, non-controlled medications, think of things for pain management and inflammation. And there's many times when patients will ask us, "Well, what do you think is really going on with me?" And, you know, generally when we give our PT diagnosis, it's not a quote, 'medical diagnosis.' So sometimes it's hard for us to tiptoe around the borders of like, "Well, there might be something wrong with this," you know, but it's like you really have to get that medical diagnosis. And, you know, when we compare, for example, like a physical therapist who has their doctorate to somebody like a chiropractor who also has a clinical doctorate, you know, they can order imaging, they can give you a medical diagnosis but PTs are left with like, "Well, let me reach out to your primary care doctor to refer." So that's some challenging and we've had one of my colleagues here, Zach Stapleton, he's written three peer-reviewed case studies about him helping facilitate diagnoses of these fractures that would have otherwise gone undetected.
So, you know, definitely an important tool, but at the same time, you know, we have other tools in our toolbox to help with a patient. So things that would be nice to have, but we don't necessarily have.
[00:14:00] Dr. Cifu: I love thinking about that because, I mean, I've certainly over the years had either patients coming back to me, or I think it's usually the therapist saying, you know, "I've worked with this person for three weeks now. I'm not making any progress. I'm concerned about this. Should we further evaluate?" It's not nearly impossible to say no to that request, right? Because you have someone who actually knows the situation better at that time. And you're going to feel horrible if you, for some reason say, like, "No!" And then it turns out to be necessary later, but it is interesting to think about, you know, the balance of, you know, what happens if therapists are, you know, really free to do that workup. And I think I would imagine, you know, in the short term there'd be some pain and in the long term it would probably be great because we all learn over time, right? And we're all like, "Huh, I guess I don't need to check that every time," right?
[00:14:59] Dr. Macaraeg: Totally. And that brings up a really good point actually, like there's definitely been plenty of articles and evidence written about how, especially when you're interacting with a patient, that if you have an MRI that, for example, has a herniated disc, how diagnostic language can actually be detrimental for a patient.
And so this is kind of actually going into the next point perfectly, you know, when we– One thing that PT does a lot of is this cognitive functional therapy in our sessions, especially those with persistent pain, like we do a lot of motivational interviewing and pain science education and even some cognitive behavioral therapy to address the huge impact of cognitive influence on their physical being. And, you know, some of it is kind of backtracking of like, "Yes, your MRI says this, but what this really means is X, Y, and Z." So, you know, it's a lot of trying to understand the patient's perception of their fear, their pain, their hypervigilance, anxiety, catastrophizing, as well as like their environmental factors and lifestyle factors, that how can we better equip them to be more successful in PT.
And oftentimes, you know, the medical approach and not necessarily I'm saying primary care, internal medicine, but you know, a lot of times the medical approach is, "All right, let's prescribe some medication. Let's get you into some psychological care," which obviously is super important for patients to treat them holistically but that's where actually I think primary care does an excellent job. Like you're able to have psychologically informed care. You recognize when a patient would benefit from psychological services and medications and the main probably referral source for a lot of our patients.
[00:16:43] Dr. Cifu: Yeah, I always like to refer to previous episodes of podcasts. I guess it's shameless self-promotion, but I like it as a way of sort of bringing together everything we talk about. We had Dr. Allison Crawford on a few months ago and she was talking about lifestyle medicine. And she drew a parallel, or a lack of a parallel, between physical therapy and lifestyle medicine where she said, you know, if you, suppose you diagnose someone with, you know, a rotator cuff injury and they need, you know, non-medical care, right? Not something that you need to write a prescription for. And for those people, you're able to say, I'm going to put them in order for physical therapy, you know, "You're going to have such and such amount of sessions, you know, and that's going to improve your outcome." While with lifestyle medicine, if you have someone who's, you know, obese, not exercising, struggling with their diabetes, and where they benefit from a lot of the things you just talked about, that sort of, you know, peri-care therapy almost, you can't send them to 10 sessions, you know, with a lifestyle medicine doctor.
And so in a way, you know, you're almost a step up over some of the other specialties that are working on this.
[00:18:00] Dr. Macaraeg: It's just a different approach, you know, absolutely.
[00:18:04] Dr. Cifu: So, let me ask, you've– I don't know if you see yourself, but you're sort of an old pro, right? You've been doing this for a while.
[00:18:12] Dr. Macaraeg: Definitely.
[00:18:13] Dr. Cifu: I wonder, sort of reflecting on it, if what you consider sort of excellence in physical therapy has changed over the time you are practicing, like, were you sort of proud of different things you did in practice at the beginning versus now?
[00:18:30] Dr. Macaraeg: Most definitely. Sometimes I reflect back over the past 12 years and I'm like, "Where has all that time gone?"
And at the same time, you know, I think back to things of how did I dare do that with some patients? You know, so there's definitely been a lot that has changed. Thankfully, you know, research is improving and we're able to track outcomes a lot better but above all, and I wouldn't be surprised if you've also felt the same with your practice, I think just confidence with my experience of understanding what can PT help, what might physical therapy help, and what will definitely not help. And just really being able to understand and explain that to patients to like, "Yep, this will definitely get better with physical therapy. Here's approximately how long it'll take."
But really, you know, when you're a novice clinician, you have these rose-tinted glasses. PT can fix everything, and really that's just not the case, and it's not productive either, you know, so over the years, I feel like I've just become more pragmatic with my approach with patients. And other things too, just offering solutions for things that won't be resolved by physical therapy. So now that healthcare has evolved into more of a profits over patients at points, you know, I'm trying to not get as frustrated with the bureaucracy of that and just be more holistic and pragmatic with our patients, "Okay, this is what I can resolve," but I think too, another big lesson I've learned over the past several years is how I listen to patients, especially when they feel they are approached or when I approach them, they seem angry or cold. I distinctly remember a time early in my career where I called my father after a day of work crying because a patient had yelled at me and blamed me for their pain. And he was also a clinician and talked to me off the ledge and made me see that in fact, I wasn't the worst physical therapist on the planet, but just might've been missing something underneath where that anger and frustration had come from.
Turns out, you know, the wisdom was wiser than my emotion. And I was dreading the next appointment with that patient, but I took his advice to ask compassionate open-ended questions, sit with an open posture and really listen to what was frustrating her. In the end, it really wasn't about me. It was just frustration with the medical system and how she had challenges with navigating certain things. And she just kind of took that out on me. And it was just a really valuable lesson with how to check my implicit bias when I feel attacked and frustrated. And that really has carried me through the years with how I interact with patients.
And not that I'm necessarily relishing to get yelled at, but anytime I do interact with a patient that does seem super frustrated, I'm like, great, this is a wonderful opportunity for me to be able to figure out what's actually going on and be able to, help them, like really, really help them and help them feel heard.
[00:21:42] Dr. Cifu: I love that.
Another thing which just struck such a parallel for me is that talk about, you know, one of the things that improves and what I feel is sort of excellence as I've matured, you know, has been the confidence which you're able to sort of show your patients, right? Which means so much to getting them through what they're going through.
A better sense of like, what's at the end of this, right? You sort of know that, you can see into the future, sometimes for better, sometimes for worse with people, but that you do lose some things, right? Because with not knowing stuff, you know, I think you do some things when you first start, which you never do now, but which on occasion were hugely beneficial, right, at the beginning and maybe losing a little bit of that naivete, you know, there's a cost to it.
[00:22:31] Dr. Macaraeg: Right. And actually a perfect example of that: there's several of us here who've gone through our manual therapy fellowship and manual therapy is a lot of manipulating joints, either with thrust or oscillations and you're learning how to manipulate soft tissue.
Almost every single one of us says after we go through that fellowship, we're like, "We're not touching them as much." You know, so it is like the more you know can almost, like you said, you're losing this part that you thought was so almost hot and sexy to begin with, then it's like, "No, actually, that might not be the best."
[00:23:05] Dr. Cifu: Now you know exactly how much damage you can do.
[00:23:07] Dr. Macaraeg: Right, exactly, exactly.
[00:23:10] Dr. Cifu: Well, Sarah, thank you so much for joining me. This was terrific. I actually like all good conversations. I think I came out having learned something and having a lot more insight into what I actually do here and what you do, which is very cool.
Thanks for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Bucksbaum Institute webpage. The music for the Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.