Elise Cantu (00:19)
Hey Onco PT and welcome back to this episode of the Onco PT podcast. This episode is juicy. When I was brainstorming this series and especially this episode within the podcast,

specialist level clinical decision making. This was probably the episode that I was most excited to talk about because this has personally been something that I have been really reflecting on and kind of transforming how I approach patient care over the last couple of years. And it really stemmed from a conversation I had with Dr. Susan Maltzer on the podcast actually a few years ago. So in 2024, we were ⁓ preparing for the Cancer Rehab Community Conference and we invited Dr. Susan Maltzer.

you know, the Malzer of a focused review of safety considerations in cancer rehab, you know, that article, we invited her to come and be one of our keynote speakers. And she, no surprise, absolutely delivered an incredible presentation, but on bone metastasis. And one of the things that was so interesting to me, and I’ve just, I’ve just been doing a lot of thinking about this. When I first started practicing, you know, the Malzer article was an is.

the Bible on safety when it comes to working with people who have cancer as a physical therapist. And there’s really wonderful guidelines on like if a person has, you know, this happening, whether it’s lab values, bone metastasis, other issues, you know, these are parameters that you can use to proceed safely in all of this. And a lot of it is like, you know, hey, if a person has bone metastasis here, well, bone metastasis here, excuse me, you know, avoid this.

Or if a person has this range of lab values, then avoid these activities, but you can do these kinds of activities. It’s really, really practical. if you haven’t, y’all, if you haven’t read this article front to back and back to front, like maybe you need to pause and do that real quick because that hands down, probably my favorite article in all of Onco PT. But when I was first practicing, that was the Bible of like what not to do.

with patients in cancer, when to not treat or when to not do these kinds of interventions. And so by the time that I was doing a pre-conference podcast interview with Dr. Maltzer, we were talking about bone metastasis. And one of the things that totally struck me to my core, I didn’t think about it for a while, but it’s like Maltzer gave me the permission to like jump forward. But she in essence asked,

the question of the listeners of which is doing more harm to our patients.

Not treating?

or dosing inner exercise with the understanding that there are bone metastases. And she said it much more eloquently. Let me see if I can reword it. Which is doing more harm to our patients? ⁓ Exercising with a bone metastasis or being inactive and sedentary because there’s a bone metastasis?

We know, you know the harm of being sedentary as an oncology physical therapist. You know this twice over from the PT side and from the oncology side of things. What kind of harm are we doing to our patients by not appropriately exercising them, even with bone metastasis? Right? And there are ways that we can do this safely. And so that has really informed a lot of

kind of this paradigm shifting that I’m working through and that I also wanted to talk about in today’s podcast episode, which is there is a version in Onco PT of playing it safe that truly has nothing to do with the patient at all. Last week, we talked about some very specific circumstances in which you might want to withhold treatment from a person. And those are totally relevant. Those are totally appropriate.

But sometimes we tend to camp out in that end of the spectrum way more often than we get into this other zone of pushing a patient too hard or too far. there’s obviously a happy medium in all of this, but we as oncology physical therapists, as a whole, especially early career oncopeties tend to stay in the overly conservative, overly cautious, overly kind of scared area of

practice. And this has less to do with the patients and it has everything to do with us.

It has everything to do with you, the Onco PT.

and that is a hard truth to hear and sit with. I’m not talking about fracture prevention. We definitely want to do that, right? Very important. There are absolutely strategies we can implement to work safely with a person who has a bony metastasis so that we can stay out of the fracture zone, right? But I’m talking about professional self-protection, protecting our own comfort level.

And if that makes you slightly uncomfortable, stay with me. Okay. You are going to want to stay through to the end of this episode because we are going to bring it full circle early in your career as an oncology, physical therapist, you want to help people, but a more pressing fear or concern or even driving value in all of this is I don’t want to cause harm.

And this is a really important distinction to make because a lot of times I don’t want to cause harm is not actually the same thing as I want to help. And that’s really what Dr. Maltzer was talking about when it comes to what’s going to cause more harm, exercising with a bony metastasis or not exercising at all with the bony metastasis.

Yeah. avoiding harm is not the same as helping or doing good in this case. And it is appropriate to have an attitude of, don’t want to harm people, right? If you want to harm people, you’re in the wrong industry, right? Get out and, God, seek help.

But this very fearful and overly protective attitude goes from, don’t want to cause harm to what if I push and it looks irresponsible, right? For on me as an oncology physical therapist. What if somebody questions my decision because I’m pushing my patient too hard, too far with this? What if I’m wrong? ⁓

I hate being wrong. And I know you hate being wrong too, right? You didn’t get into this field because you like being wrong about things. You like learning things. You like knowing things and you like making an informed decision to help a person. And this being wrong is totally antithetical to all of that. Like it doesn’t feel good. It doesn’t feel good not to know things, not to know that you are absolutely making the right decision in this. And so when this fear of

I don’t want to harm somebody enters the room. Restraint feels safer. Being overly protective, overly cautious feels like a better, safer decision than potentially pushing a person who has a bone metastasis, for example. And this doesn’t mean that it’s even clinically safer, but professionally safer from a comfort level. And when I say professionally, I mean you as the professional in this decision-making situation.

Now there is a difference as we mentioned previously between protecting your patient and protecting your comfort. Sometimes they’re the same, but a lot of times they’re not. A lot of times they are truly different. Protecting your patient, which we absolutely want to be doing, involves monitoring their vitals.

and looking at their medical stability, decreasing fall risks. So if I’m doing balance interventions with my patient, then I choose professionally to use a safety belt and I’m guarding them. There’s protocols that I put into place to make sure that I am being as safe as possible with my patient, that I am protecting my patient when we’re doing XYZ intervention or activity. I am monitoring

their tolerance of the activity or the exercise that we’re doing. And I’m also checking in with ⁓ the dosing. Am I calibrating the dosing appropriately? Is this the appropriate prescription for this person? Am I pushing them too hard? Do I need to maybe back it off because they look like they are working really, really hard at this thing and I don’t want it to be that hard. Or maybe they’re not working hard enough so I’m gonna push them just a little harder. I’m gonna increase that weight or those repetitions, right?

Protecting our patient is doing all of those things, is monitoring these things continuously, consistently to make sure that we have the safety measures in place to protect our patient appropriately. Protecting your comfort is different. Protecting your comfort involves avoiding risk.

and going overly out of your way to avoid risk. ⁓ Staying comfortably conservative in all of this. I’m not going to push this patient too hard, because I’m worried if I push them too hard, then XYZ and then this cascade could happen. Or even defaulting to the lowest common denominator. One of the things I think about all the time with this is our three sets of 10 dosing that we love to do as physical therapists, period.

when that may not be the most appropriate thing for our patients. And I do want to acknowledge sometimes protecting your patient, protecting your comfort are going to overlap, but sometimes they don’t.

And a lot of times early oncology physical therapists are going to default to protecting their own comfort.

more so than really thinking strategically about protecting their patient. They’re thinking, you might be thinking you’re protecting your patient when in fact, protecting yourself is more at the core of why you’re choosing to do things. And this is where the growth happens. When you really start to choose protecting your patient over protecting your own comfort. And recognizing that there is a difference.

and when you need to make different choices in order to prioritize protecting your patient over protecting your own comfort. Clinical courage, pushing a person, pushing with interventions is not reckless progression, right? You’re not going into a clinic and not looking at this person’s chart or ⁓ kind of medical circumstances.

and blindly assigning them to be doing one rep max on the, you know, the squat machine, a single leg, et cetera, right? That is not what we’re talking about. We’re not talking about recklessness here. What we’re talking about is deliberate progression with documentation, right? Because we want to see like, what did you do? Right? You know, so that way the next time you can say, okay, this worked or this didn’t work. Here’s how I’m going to change it next time with

very intentional reasoning and with continuous monitoring during this process. So we’re documenting what we did, we are thinking through this strategically, and we are also monitoring to see what this person’s tolerance is in all of this. And you’ll see that these really mirror the protecting patient safety values and core components that we talked about previously in this episode.

As you’ve heard me say in this podcast arc, the goal is not to eliminate fear in all of this. You’re human. Fear is inherent to us as an evolutionary concept to protect ourselves. But sometimes we have to know when to say, okay, fear, I hear you, I see you. I, as in your highest self, your most knowledgeable, intelligent,

You know, oldest, wisest part of you is going to take over and say, I hear you fear. see you fear and I hear you. I hear what you’re saying and I’ve got this. I have the knowledge and the clinical decision making skills to make the appropriate choice in this situation. I got this. So you don’t have to. And again, I’m using you as I’m talking to fear directly in this case. So you fear don’t have to feel like you have to take over.

You don’t have to be in charge because I have this taken care of. I have this handled.

And part of being able to get to this point is to recognize when fear has shifted from protecting the patient as the core focus here into protecting your own comfort, to protecting yourself. And again, this is not to say be reckless, to just throw exercises and whatnot willy-nilly everywhere. We are still protecting yourself and your license, right?

But from a clinical perspective of you may be very overly inappropriately conservative with your patients and that is keeping them from truly improving, truly getting better, truly getting to the point where they can accomplish their goals to do the things that they wanna do with the people that they love. That is specialist level awareness. There have been moments in my practice where I realized I wasn’t holding back because of

you know, there’s something happening with the patient that I’m concerned from a safety perspective. It was because I was holding back because I was the person, I was the PT. I didn’t want to push them too far. And I think a great example of this, I’ll talk a little bit more about this case actually in next week’s episode, but ⁓ I had a patient, we’ll call him Pablo. So Pablo was a patient that I was working with ⁓ and he had known bony metastasis. We knew this.

But Pablo also had goals. Pablo also had things that he wanted to do that he wanted to get back to. And there came a point when I was working with him that I realized we have plateaued in this current approach that I am applying in our plan of care. And if Pablo really wants to get back to doing XYZ safely, and I know I can help him do that, we have to push the boundaries a little bit.

Now I am going to pause because I’m going to make you wait until next week’s episode where I’m going to talk more about Pablo’s situation. But this comes with sitting in that discomfort, right? This is a theme that we’ve been talking about multiple times over the past few episodes of I have to sit with that discomfort of being like, you know, we’re here at point A and we want to get to point B. We are never going to get there using the same path, using the same

methods that we have been using for the past however many sessions or whatever that looks like for you. You have probably done something similar. You have probably worked with a person at this point who even if you didn’t recognize it in the moment, maybe this is your kind of realization, your ⁓ light bulb moment of, ⁓ that’s what this is for me. And again, I’ll talk more about Pablo in the next episode.

But you probably have a patient encounter that comes to your brain right now where you can say,

Yeah, that was a situation in which I was being too conservative. I was being fearful. I was letting that fear drive that session and my interventions instead of my confidence in my clinical decision making to know that this is the most appropriate decision for us right then and there.

This also comes with having these realizations and these discussions and these conversations, not just with yourself. Right. And this is why we talk about the cancer rehab community all the time. This is why it’s so important for us as cancer rehab professionals and future professionals. Right. Maybe you’re listening to this and you’re like, I want to get into onco PT. I’m not there yet. That’s okay, friend. This is the space for you too, because when you’re surrounded,

by other oncology clinicians who are navigating these same boundaries and fears and concerns and whatnot, your perception of risk recalibrates. Like what was previously a really, really risky decision, treatment-wise in your mind, can shift to a, this is a little more of a moderate risk than I was originally. Like it goes from high risk to medium risk. Or maybe it goes from medium risk to low risk.

provided that you are making that decision intentionally, right? This is when you really start to put together that thoughtful progression is not recklessness, it is clinical maturity. And these are the steps that you have to take to become a specialist in oncology physical therapy, to have that specialist level decision making as an oncopT, so that you can truly be the best possible oncopT that your patients need.

If you have been playing it safe, take a breath, right? It is okay, but I’m gonna ask you something that I really want you to sit with as we close out of this episode. Is this protecting my patient or is this protecting my comfort?

And a lot of times those are different. And I really want you to sit with this question and answer truthfully, sincerely. Is this protecting my patient? Is this protecting my comfort? And this question alone can completely shift your on-corp PT practice. As I mentioned earlier in this episode, next week, I’m actually going to talk through a real case.

so that you can hear what this kind of calibration looks like, sounds like in motion. So that you can take this example and apply it to your practice, your patients, so that you can really discern and move forward from, this protecting my patient? Is this protecting my comfort? And where do you go from there? Until next time, this is Elise with the OncoPT. And remember, you are exactly the physical therapist that your patients with cancer need.

So let’s get to work.