"No patient is broken"

Disc disorders. There is this narrative: something has slipped out, become dislocated, broken. The back is understood in extremely mechanistic terms. Yes, there are herniations that can be understood mechanically – when nerves are involved, you have to act. But in most cases a herniated disc does not need a mechanical solution.

The twist: yes, there is damage here, and it cannot be healed. That is the first shock. But: we can do very well at ensuring that you don’t notice it. My body is no longer intact, and it never will be again – but even so, I may well have no problem with it – especially if I take ownership of it. Far too few patients receive this message.

Too little. Anyone who uses fear as a basis for their argument – “if you don’t do this, in ten years you’ll have a back you can no longer move” – is doing something fundamentally wrong. It harms people. And as a doctor you become associated with the bad news.

Honesty without panic. Yes, you have facet joint arthritis. It can cause pain from time to time. But if you do something, keep your back muscles healthy, stay mobile, you have a good chance of rarely having problems. That is a completely different story from: you are broken.

To handle nocebos carefully. Because if we send patients to physiotherapy full of fear and catastrophic thinking, the therapists have an unnecessarily hard job correcting that. We make their work harder before they have even begun.

With overly generous imaging, the harm can outweigh the benefit. Not only because of radiation exposure – but because you discover things that then have to be investigated further. Sometimes very invasively and expensively. Incidentalomas, incidental findings. Disc bulges are the classic example.

A big one, it has to be said self-critically. The system sets the incentives wrongly: the MRI is well reimbursed, the honest conversation barely at all. Such incentives steer behaviour more than many people realise – even when an image brings no medical added value.

Imaging is a means of replacing the time you don’t have. You can tell the patient: go into the tube. Afterwards they have the feeling that everything has been looked at. That replaces the conversation that would actually be needed.

Because orthopaedists get zero euros for explaining. You are massively penalised for it. Really, you should sit down for 20 minutes, go through the images, show a diagram. That would let you tell patients a completely different story from: you are broken.

The complex conversation. A consultation code: spoke with the patient for over 15 minutes. There should be something like conversational orthopaedics.

Exactly. There lies a huge opportunity. Physiotherapists spend far more time with patients than we do. They could take on the education that we cannot provide – explaining why movement helps, why the finding is not a catastrophe. If physiotherapy takes this role seriously, it can bring about behavioural changes that we orthopaedists, working in five-minute slots, could never achieve.

The aspiration to make patients competent is not trivial. It requires being outstanding both as a person and professionally. And the profession is undervalued – the reimbursement for physiotherapy is far too low. Collaboration, communication – the system makes no provision for it. What is wanted is: high throughput, treating the masses.

Asynchronous. Via the electronic patient record – if I need something, I can look at the therapy report. Not constant phone calls. But if the course deviates from what was expected, a signal should come through.

That people become competent at activating their own resources. Not: I need an external person to “put me back in place”. That overwhelms the healthcare system massively. I tell my patients in advance: after six sessions you should be able to help yourself and know how to prevent things getting worse – for example through long-term training.

When patients come back and say: they did passive therapy, even though I prescribed active physiotherapy. Passive therapy has its justification – as a bridge to activation. Not as a permanent solution.

Where a passive approach focused on “putting things back in place” dominates, dependent patients easily emerge – people who believe they cannot cope without treatment and come twice a week. That is not therapeutic success but cements the dependency. That is exactly what good physiotherapy should avoid.

There I have to say self-critically: we doctors often credit physiotherapists with too little. We treat them as people who carry out instructions, not as experts. Yet good therapists have a deep understanding of movement and load management – often better than ours.

For me it’s very clear: I make the diagnosis. The physiotherapist makes the treatment plan. If I say: upper crossed syndrome – then the physiotherapist decides which concept to follow.