Ep 544 – Clinical Experience: Asset, Liability, or Both? with Doug Nelson

0:00:00.2 Speaker 1: Precision Neuromuscular Therapy has been teaching high quality seminars for over 20 years across the country. Founded by Doug Nelson, PNMT uses problem solving skills and precise treatment options to get powerful results for your clients. PNMT seminars focus on honing your assessment and palpation skills to precisely target the source of your client's pain while understanding the why behind the what. Meet us in a hands on seminar or online in the PNMT portal and let us join you on your learning journey. Learn more at pnmt.org. Elevate your bodywork career with Anatomy Train's structural integration certification, ATSI. Discover how to map the pattern and shape the change through inspiring lectures, hands on body reading and practical techniques you can use in your practice right away. Join us for ATSI Maine 2026-2027, where Tom Myers will personally kick off this transformative professional training. Learn more at anatomytrains.com/atsi.

0:01:28.6 Doug Nelson: I'm Doug Nelson and you're listening to the ABMP Podcast, a podcast that speaks to the massage and bodywork community. As a clinic owner, countless times in the past I've had potential clients ask to be placed with one of my most experienced therapists. They'll often say, "Tell me who on your staff has the most experience. I want to see your best person." Well, the embedded assumption there is that the person with the most experience is also the person who can create the best outcomes. And in this podcast, I'd like to explore both sides of the value of experience. Because there are times when experience is truly invaluable. But there are other times when, surprisingly, it's actually a limitation. First, let's explore the obvious thing where experience is actually an advantage. Years ago, I shared this story in a Table Lessons column about a friend of mine who's an engineer who lived next to an orthopedic surgeon, and they would get together in the surgeon's basement, have a cocktail, and then watch videos of rebuilding a joint, that kind of thing. And my engineering friend at one point, after hours of watching these things, said to the doc, "You know what?

0:02:47.3 DN: I think 98% of what you do, I could do, because it's really just engineering." And the doc, taking a sip of his drink, looked at my friend Larry and said, "You know what? That's true. But here's the thing. It's the other 2% that really matters." And that's the value of experience. It's all good as long as everything goes well. It's what happens when things go off the rails. Then how do you respond to that? And that's what experience can do, because you may have seen those kinds of things in the past and have confidence in your ability to do that. It makes me think of the years ago, there Farmers Insurance, I think it was, had this tagline of, "We know a thing or two because we've seen a thing or two." That's what experience can do. So for a therapist, if you've had those experiences before, you may have seen multiple variations inside of that, and so that's one thing. Or even if something happens that you haven't seen, because you have a history of dealing with those kinds of novel situations, you have confidence in your own ability to respond appropriately. And that's part of what training and experience can do.

0:04:02.4 DN: And we certainly see that represented in flight training for pilots. I recently got a chance to do that, just to sit in one of those flight simulators and see the multitude of things that the person controlling it can throw at you just to challenge your abilities. Not that I have any abilities in the first place, but it was a really cool thing to see it. And then a few weeks ago, I took my staff to the University of Illinois, Carle Illinois Medical School simulation lab and saw the same thing in medicine, where, for instance, there's a mannequin. This thing is amazing, this mannequin. It's all wireless, it's all computer controlled, but it can give birth in a multitude of ways, most of which are really problematic. And for a medical student in obstetrics, can actually see all sorts of ways that things could go terribly wrong and learn how to respond to those situations with this mannequin and not do it in a real birthing room where that's probably not the place you want to practice, right? And so the value of that simulation is so important, and it was really cool to be able to see that.

0:05:16.2 DN: So one of the great values of experience is really pattern recognition. Sometimes my staff will quiz me or question me like, "How did you get to that so quickly?" because they're going through a multitude of processes that I cycled through at a really high rate of speed to get to the source of the problem. Ultimately, again, it's pattern recognition. Having seen so many clients, my brain and the brain of experienced practitioners just go through those processes really, really quickly and oftentimes will take leaps and shortcuts called heuristics. Those are developed over time and experience. You would assume, right, that, well, this is what we're all shooting for, correct? Well, kind of yes and no. Studies in the field of medicine and psychology have really thrown doubt on this idea that experience makes practitioners more effective. In fact, in many cases, effectiveness decreases or plateaus over time. How in the world could you be less effective with all that experience? One answer is, as it turns out, the same processes that make experience valuable also have a shadow side. And I've actually seen this in myself with my mentoring work with my staff. Again, as I said, oftentimes I'll cycle through a bunch of processes really, really quickly.

0:06:00.3 DN: But lesser experienced therapists have to think through those same processes one by one to come up with some sort of appropriate response. When I am mentoring, I have them do that out loud. They have to verbalize to me the whole process. "Here's what I'm thinking, here's how I'm gonna respond, here's what my expectations are, here's what the next step would be." I have to say, there are times when I find myself a little surprised because I realize that they caught something that I didn't catch, or sometimes they'll question an assumption that I made or notice something that I completely overlooked, honestly, because it didn't quickly fit into the pattern I thought I was seeing.

0:07:29.9 DN: They're actually using a more active reflection and they're less quick to speed through that process. It's tempting for someone like myself to make everything kind of fit into a box that I'm familiar with or to default to favorite approaches or techniques, even when those don't seem to match the client's need. And believe me, I think that's true for a lot of therapists who've been practicing for a while. You get into your groove, you're into your favorite things, your favorite muscles, favorite approaches. But having your decisions questioned, having to respond to somebody else is a really, really good thing. And jumping to conclusions like that, something called premature closure, can be really problematic. It can be an asset in terms of speed, but if speed is inversely related to accuracy, now it's a problem. So there seem to be several keys to improvement over time, but maybe at the top of these is reflection. I'm sure you've heard of the 10,000-hour rule, the 10,000-hour principle, that that's how many hours it takes to get to be an expert.

0:08:41.1 DN: And this really got grossly misinterpreted because if doing something a lot made you better at it, I know a lot of golfers who should be fabulous by now. But turns out if you practice your mistakes, you will get better at your mistakes. And there's several ways that this can happen, as you might imagine. But in our world, there's something, here's an example, it's called therapeutic drift or technique drift, which is that maybe I'm evaluating someone who came to one of our seminars and I want to evaluate doing a practical exam. And I'll say, "Treat this particular muscle." And as I do that, I look at this and think, "I'm not sure where that came from, but that's not what we teach in the seminar." And people look at me like, "Well, yeah, it is." Like, "Well, no. And I would know because I taught the seminar and I wrote the book. So, yeah, I think I would know. Let's look at this again." And what happens is this kind of drift is that they go back, they're by themselves, and now that what is taught is kind of incorporated with a multitude of other influences or the thing that they're most comfortable with.

0:09:55.7 DN: And pretty soon it's like that telephone game that things just change over time without them realizing it. And that would be fine if they got fabulous results. But many times I'll say, "When you do this, is this effective? Do you get the results you're hoping for?" And then they'll give me that funny look of, "Well, actually, no. I don't really like doing this because it just doesn't seem to help. And I know you said this would be good for whatever, but it doesn't seem to work." It's like, "Well, I have a couple ideas why. Let's go back and do it a way that we have found over the years to be effective." And this is perfectly understandable because there's no one at that time to help them correct course. A client is not going to say, "You know, is that really what you learned in the seminar?" That's not going to happen, right? So client feedback isn't really helpful in that. The only thing that would be helpful is somebody who actually knows. And this is where mentoring or being in a seminar with another person who did that, so you have something to bounce back and forth with to correct mistakes and correct nuances.

0:10:57.6 DN: And so making sure that over time accuracy doesn't fade. It's understandable again, when people practice alone, that they're subject to this kind of drift. But the reality is so many people in our field, if not the majority, do practice alone. And this is again the value of mentoring. And also what makes it worse, truthfully, sadly, is that when you have a full schedule of clients who are always returning and you're never seeing new people where you're challenged by novel situations, boy, that kind of decay and drift can really accelerate in ways that we as therapists don't even recognize over time. And it's understandable because people still think, "Well, I must be pretty good because my practice is really full." That's not the bar. The enemy of the best has always been the really, really good. And so again, this speaks to why mentoring or an outside influence is so important. Companies know this, organizations know this. That's why they hire a consultant to come in and look at this with whatever they're doing with fresh eyes. We all could use that help in that way to help us be the best therapist we could possibly be.

0:11:57.7 DN: In summary, a clinician who's "seen it all," seen a thing or two, can over-rely on history and past cases, miss subtle new information, maybe sometimes stick to favorite or maybe sometimes outdated models, or just become a little less flexible in treatment planning of, "This is kind of the way I do it. This is what I found that works. This is my massage." And then it really becomes kind of a rigid approach to things and not something that you would really recognize yourself unless reflected back to you on the outside. So it's really hard to keep a beginner's mind. And how do we do that? How do we have a beginner's mind and have the wisdom of experience at the same time? Here's a couple ideas. Reflective practice is certainly one of the top things. Just question yourself, question the assumptions that you make.

0:13:09.9 DN: One of the primary questions I ask myself every time I see a new client who presents, I only see people with very specific problems, but my first question is, what makes me think this is soft tissue in nature? Soft tissue is my expertise. It also means it's my blind spot. Not every problem is a soft tissue problem. So let's get that out of the way first. And if I can't defend the idea that this is primarily soft tissue, boy, the alarm bells should go up and I should stay open to other possibilities. The same thing if you're somebody who is toward a certain modality, if you do fascia work or whatever it is, what makes me think this is the appropriate response to that? Can you actually defend that? Because there are a multitude of reasons that someone might be in pain or discomfort. And how do you know that your response is the appropriate one? We have to question these things. Or even just something as simple as how do you know that where you are is where you think you are anatomically? Could you defend that? If somebody challenged you to say, "What makes you think you're on this structure or this muscle?"

0:14:20.0 DN: Can you clearly defend that? I think that's a really important question to ask, as simple and fundamental as it is. Speaking of fundamental, why did you start the session where you did? Or why was the client in that position to start the session? And the answer really cannot be, "Well, this is the way I start with everybody," right? Because now you're saying, whatever the question, this is the answer. A really cool strategy, I know it's laborious, but mapping out the sequence of the session. What were the choices you made? Why did you go from here to here? Why did you spend this much time there? Is there really a rationale behind all of that? Or are you just kind of defaulting to something you're comfortable with? That kind of reflection will make you better. Cross-domain learning is another thing. Oftentimes people will ask me, "Where are your sources of inspiration?" And for me, most of them come from other disciplines. Recently I presented at a national conference on social work about the shared tenets of psychological approaches and somatic approaches, but the ideas kind of behind them, really, some of these same kinds of things.

0:15:34.2 DN: There's a lot of data in the psych world because they've been around for so long and have got really good data. There's a lot I've learned about effective practice from them. It's not about the technique, it's about much more, much greater overarching principles. Or just a discipline that you pursue in the arts or the athletics, where that discipline, those fundamental things you apply back to your practice. For me, it's studying the cello and honestly, becoming a cello student has made me a better teacher because it's so incredibly humbling. Ultimately, it's about fostering curiosity. You're never curious about that which you think you understand. Curiosity just blows away assumptions. Because Einstein said, what holds us back isn't what we don't know, it's what we think we know. Because when you think you know something, you're never curious about it. Step back, listen to the questions that your clients say. Dive into things instead of making assumptions about them. Just be endlessly curious. Another approach, seek a mentor, or if you've been practicing for a while, be that mentor. Learn a new approach with a colleague. Attend a seminar with a colleague so you can go home and work together.

0:17:02.0 DN: You need an outside influence. And again, sometimes being a mentor is just as valuable as being the mentee, because it's all about questioning. Each one will benefit from the other. So if there's a way to do that, please consider doing that. It's all about ways to get valuable feedback. And if feedback doesn't challenge you, it doesn't change you. Seek feedback from clients in very, very specific ways. And I tell people, don't tell me what you think I want to hear. I want to know, did this make a difference? Somebody I saw today said, "I feel so much looser." And then she also told me that her pain hasn't changed at all. It's like, well, I like the idea that you feel looser, but what I'm really interested in, why you came in, is because of this unrelenting pain. So nice, but we're gonna keep going until I see a change in the frequency and the intensity of your pain. And she was like, "Oh, wow, okay." I could tell she was a little bit uncomfortable in sharing that the pain hadn't really changed. And again, she was a little surprised that I was kind of embracing that feedback.

0:17:38.0 DN: It's like, okay then, here we go. I think that's a really important thing, both as a therapist, and I think your clients will really appreciate that. So, like so many things, experience can be an asset or it can be a liability. So in closing, I invite you to develop a practice that's inspired by endless curiosity, constant reflection, and a commitment to creating excellent therapeutic outcomes for our clients. Thank you for joining me on that journey.