That Grinds My Gears: Trainers Playing Pretend

[Jason Silvernail]

You know what really grinds my gears? When fitness people play pretend doctor.

They pretend expertise or experience in the evaluation, diagnosis, treatment, and management of a medical problem - usually a painful problem that is musculoskeletal in nature. Oh, I get it. You saw a client once who told you their [insert medical practitioner here] told them something that wasn't right, and then the client did something you coached them in, and the client told you they felt better. You cured them! Wow, you are smarter than that dumb old [doctor, physical therapist, etc]. Riiiiiight.

Latest entry from Mr Eric Cressey, here's what I tweeted just now:

What's funnier "trainer playing doctor" or number of medical marketing gimmicks? ?RT @ericcressey: Corrective Exercise http://t.co/6aj1cw8

Now I happen to like Eric Cressey's website and think he's probably an outstanding coach and trainer. He also calls foul on a lot of crap that physical therapists, chiropractors, and physicians do that is spot on and worth mentioning. I've retweeted his material and I've written him "thank you that needed to be said" messages before. He does a lot of stuff right, so this isn't a personal attack on him.

I discussed this issue a while back in another thread and I'll repost that here:

"Maybe I look at these issues too simply. I think someone is either a trained healthcare provider capable and responsible to examine, diagnose, and treat someone - or they aren't.

If I have a patient with a suspected non-musculoskeletal problem, I don't speculate on what it could be unless there is an evidence-based screening criteria I am using, and I don't offer advice or suggestions on treatment since it's outside my area of expertise. I make the referral and move them on, then encourage them to follow the advice of the appropriate clinician and reinforce that advice when I'm aware of it. I realize that for those issues, I don't know what I don't know. I have enough education to be able to explain the physiology of things outside my area of expertise when a diagnosis has been provided by a qualified person (a frequent task for me in my extended family and I'm happy to do it), but I try to be very clear about what I can and cannot do and what I do and do not know. [This is a basic responsibility of any healthcare practitioner]

I have seen a lot of fitness type folks who seem to be evaluating and treating medical problems, and I think they are one wrong move away from a bad outcome for both their client and themselves - because they don't know what they don't know."

Ironically, fitness and massage people are in a position to positively affect their client's health maybe more than any medical person like me. They can get involved in their life on a somewhat long term basis and steer them toward a healthy lifestyle and provide sound advice on areas they have expertise in. They have so much, and in many ways so much more than medical professionals, to offer that I am bewildered that so many often speak beyond their expertise and training. If you have not had basic science education and training in the evaluation, diagnosis and management of real medical problems then do not pretend you have! This involves real training in real healthcare settings with real sick patients. If you have not had this training you don't know what you don't know. And that can hurt your clients and your career.

[Frédéric]

Music to my hears. Almost like an echo.

The problem is that many of these practionners/trainors where led to think they actually know what they don't know in their training.

[student]

Jason, this is sad but true. I have seen it happen too many times. The scary part is that these clients look up to you as a trainer and trusts you as a medical professional. I have to refer people out multiple times a day and suggest they see their MD to answer their questions all the time. There seems to be a pervading theme among trainers that PT's suck as a group and MD's don't know anything. However the trainer happens to know (Insert the latest CEU course they attended) which can cure all ills. To me its like a little kid who is told that the big animal in front of them is a cow and so they go calling every animal they see a cow for the next while. Every once in a while they may be right. And if they live on a dairy farm they may be right fairly frequently. But at the end of the day the don't understand what makes a cow a cow or another animal "not" a cow.

This was and has been a huge debate for quite a while now especially when "pre-hab" or "corrective exercise" is being discussed. In the end you need to excel at whatever it is that you do. I know a number of PT's really have no business trying to work in the strength & conditioning realm as well.

[Jason Silvernail]

I know a number of PT's really have no business trying to work in the strength & conditioning realm as well.

Great point, Scot. Far too many people with physical therapy degrees try to act like strength coaches or personal trainers and of course do a horrible job at it because PT school isn't designed to prepare you for that.

Love the cow analogy as well. Think I'll keep that one.

[NateM]

Some of this stems from PT's entering into personal trainer conferences and courses, offering up PT-type material (assessment techniques, treatment techniques, etc) to personal trainers, whose background can vary tremendously. The PT's get to look like experts, but they don't seem to ever mention that what they are teaching may be beyone the scope of almost every trainer in every state.

Look at the National Academy of Sports Medicine. Headed by a PT, they offer the classic postural/movement assessment material and the "corrective exercises" needed to fix every problem. Damn, instead of investing three full-time years and tens of thousands of dollars at PT school, I coulda just become a "Corrective Exercise Specialist" for $700. What a fool.

[Jason Silvernail]

Agreed, Nate, that physical therapists are responsible for this ridiculous "corrective exercise" thing, along with the "trasversus abdominis" thing, and the "prehab" thing. We have plenty of blame for this phenomenon.

[Johnny_Nada]

I might like to add that the NASM-CES and NASM-PES is an open book test....

[Headcmu03]

I am both a personal trainer and a S/C coach and unfortunately have witnessed this too often as well. I don't know why it happens and it was clearly talked about in my undergrad exercise science program what our boundaries are as exercise professionals. Since we're venting, most personal trainers don't even have a degree in exercise science.

[Jason Silvernail]

Matt thanks for the info about NASMs certs which are terrible about the medicalization of fitness training.
My wife is a personal trainer and while getting her MS in Ex Sci and Health Promotion, the school was "partnered" with NASM and there was a whole certification track she was required to take even if she didn't sit for the cert. We laughed about how bad the material was but she did what she had to do for the NASM classes to pass. It was like they spoke out of both sides of their mouth: one side said "you don't diagnose things" and the other side said "here's how you diagnose things".

She often gets those questions but sends people back to their healthcare providers. She has basically said that she has lots of important things to talk about with her clients regarding health and lifestyle as it is - without having to pretend that she's a physical therapist, dietitian, or physician.

[caro]

Ironically, fitness and massage people are in a position to positively affect their client's health maybe more than any medical person like me. They can get involved in their life on a somewhat long term basis and steer them toward a healthy lifestyle and provide sound advice on areas they have expertise in. They have so much, and in many ways so much more than medical professionals, to offer that I am bewildered that so many often speak beyond their expertise and training. If you have not had basic science education and training in the evaluation, diagnosis and management of real medical problems then do not pretend you have! This involves real training in real healthcare settings with real sick patients. If you have not had this training you don't know what you don't know. And that can hurt your clients and your career.

Hear, hear.

[student]

Two quick things...

In Erics defense he did mention that the hands on work was done by Dr so-and-so. I still don't agree with all the ideas but did want to point that out.

In my opinion strength and conditioning is something that is well within the scope of a PT who has spent the time to educate themselves on it. However no matter how much self study the trainer does the ability to examine diagnose and treat is legally not within their scope of practice. I have a PT friend who sat in on a elite trainers class for a upscale gym and they were arguing that if they can't deal with the PT related topics then the PT had no business dealing with what they do. I disagree. My stance would be PT has no business messing around with something they don't understand, which very well could be strength and conditioning.

[Jason Silvernail]

Yes he did, but also spent the rest of the post explaining why a medical person doesn't know what they are talking about but that he does. Then he talks about "soft tissue work" (whatever the hell that means) and trots out ART etc. Now for all I know the gentleman in question got a poor physical therapist - but that's tangential to the point here in my opinion.
This isn't the first time Mr Cressey has claimed he has "rehabbed" someone's injury that a medical professional could not. He's on thin ice as far as I'm concerned - I hope he doesn't mistakenly hurt someone.

[thrill96]

So, Jason and I had a "conversation" via text and he thought it would be a good idea if I wrote some of it here.

Last summer, along with a PT and a chiropractor, I did a whole seminar series on the body. We started at the foot and make our way up to the lower back. We would start the month with the chiro who did presentations on nutrition and basic physiology/neuroscience, then we would move to basic anatomy and some pathologies led by the PT and then I would finish the month with biomechanics and how to apply those to fitness. NEVER did we encourage anyone to diagnose or treat anyone. Actually the opposite. We insisted that folks refer out to the PT or chiro or MD, if necessary.

The chiro actually went into a big presentation on how issues presented in the neuromusculoskeletal system could be coming from a host of other causes other than that system.

We would talk about the different pathologies but again NEVER encourage them to diagnose. It was an education for them so that they could understand these pathologies and refer out when necessary.

I even went into a very long presentation on "All low back pain is not musculoskeletal in nature". I told them how I had a client who had recurrent back pain. It would happen at the same time every month which coincided with her period. Hmmnm....well, her doctor didnt pick up on it. So I did a little research and found low and behold that women with a retroverted uterus can have back pain. Well, I actually took her my book, showed her and said "please discuss this with your doctor." No matter what kind of massage work we did, it would always happen. Now, she did know she had a retroverted uterus but the doctor never put it together with the recurrent back pain. NOW, this did not make me cocky at all. It actually made me more aware of what kind of business can happen in the body that may present at as musculoskeletal but be far off. I tried to relay this info to the trainers. "Refer out. Don't assume. Don't assess. It's not your job and you dont want the liability. Your clients will appreciate you much more when you do." I am pretty sure I stayed with my scope of practice by educating her on the issue and not treating her (I mean, how could I?). It put her mind at ease to know it was a pathophysiological issue. We continued to work together but we would always be aware that at a certain time, her back would get a little cranky and we did what we could to keep her calmer and more relaxed. However, being a mom of three and a wife, well, that always didnt happen.

However, I routinely see trainers doing exactly what we encouraged them not to do. One client mentioned to a trainer that he was having pain in his gluteal region to which she promptly replied "It's your piriformis." WTF????

HOW IN THE WORLD DID SHE KNOW THAT? I mean, come on. I informed the Fitness manager that this was going on, and I believe she mentioned it. It happened multiple times after with another trainer who had a client with hip issues. I told the trainer to INSIST that she go to the doctor. It could be anything. I think he mentioned it but when I felt like he didnt, I again informed the fitness manager. We both sat him down and told him about the liability that he was bringing himself, the club and me because now I had knowledge of this. We have a medical release form that a member can fill out to release us of any liability instead of going to the doctor. So we gave her this and she happily signed off RATHER THAN going to the doctor. Sigh...

I lost this duel-client and the trainer and I didnt talk much after that. Don't know but I sure as hell wasn't going down because two people were being hard headed.

I'm actually at a loss here because there seems to be several drivers/motivators from several sources in the trainer, client/patient, PT, MD, LMT, DC that can come into conflict that does lead them to seek the proper professional advice.

Sure I've caught a few weird things here and there BUT I always refer out with a note to the doctor and I will not see the client until it's been cleared. If they choose to leave me, then so be it. My interest is their health and not their ego and to be honest, my livelihood. I dont want to get sued for negligence. Doctors get paid WAY more than me and pay much more insurance. Let them take that liability on and if they sign off on working with a trainer, PT, DC or LMT, then so be it. I'm so over my ego getting bruised.

Sorry for ranting.

Will

[Diane]

You are allowed rants like this, anytime. Good rant.

[student]

Point taken Jason.

Will, yea its worth sticking to your guns on. I have clients and gym members ask advice on a host of medical issues very frequently. For the most part I listen to their complaints and then suggest they see PT or their MD. I also try to insure all of my trainers do the same. Not always what they were looking for... but its what needs to be done. I think its an easy trap to fall into but one that is worth taking the time to avoid. A little knowledge is dangerous.