E20: Why PT school isn’t enough: clinical reasoning, uncertainty & better care with Joel Sattgast

Jimmy: Welcome to the Physio Insights podcast presented by Runeasi. I'll be your host, Doctor. Jimmy Picard. I'm a physical therapist, running coach, and team member here at Runeasi. On this show, we have real conversations with leading experts, digging into how we recover from injuries, train smarter, and use data to better guide care.

Whether you're a clinician, a coach, or an athlete, we're here to explore what really matters in rehab and performance. Let's dive in.

Jimmy: Alright. Everyone, welcome Joel Sattgast to the podcast. Joel, I am excited to have you here. I've known you for probably five years. We met at Chris Johnson's house a few years back.

For those listeners that aren't aware of you, that don't know you, would you really quickly just give us a little introduction?

Joel Sattgast: Yeah, sure. Thanks for having me on by the way, Jimmy. So a little bit about myself. I'm a clinician, I'm an academician and I'm a coach. So I kind of wear a couple different hats.

My primary gig, if you will, is I work in academics with Eastern Washington University, and that's located in Spokane, Washington. I also run a both clinical practice and a coaching practice. And that's a solopreneur type of offering. So I'm employee number one, but also wearing all the hats associated with that. And I know there are some similarities between us in that in that regards, Jimmy.

And then, you know, outside of the professional realm, personally, I think these are maybe the more important hats I wear. We were chatting just a moment ago. I'm a dad, I'm a husband. And so those are also some other areas of my life.

Jimmy: You left one thing out there. You're also a runner, an athlete.

Joel Sattgast: Yeah. There's that too. So so I'm, I guess, a washed up has been athlete. I still try to compete pretty competitively. Having had the opportunity to play two sports in college, my overall ceiling perhaps has lowered a little bit.

But yeah, anytime I can mix it up, it's a good day.

Jimmy: Awesome. Well, Joel, I really appreciate you coming on. And I think what you just brought up a good starting point. So I did not know that you played two sports in college. Tell me about that.

Joel Sattgast: Yeah. So I was fortunate to be able to to play both collegiate soccer and run track and field. And coming out of high school, I didn't think either one of those would really be opportunities. Not because I didn't necessarily have the skill or the capacity, but because with kind of the direction I wanted to go within college, I didn't know if I'd be able to kind of juggle multiple constraints of my time. So when I went into undergrad, I went in with the idea of kind of pursuing a pre medical background or pre medical emphasis.

And I knew that would be fairly strenuous or rigorous academically. And so then I was a little bit concerned about what happens if I try to kind of juggle these sports as well. I opted not to go or pursue kind of a larger university setting. So Division one or Division two, I ended up playing in the Midwest instead. And it was a really nice opportunity to still play at a fairly high competitive level, but not at such a high level that that became kind of the main emphasis.

I was athlete first, student second, rather I was able to kind of do both. And I really enjoyed that. It still stretched me physically and competitively and had a really good experience overall. So

Jimmy: yeah. Yeah. That's awesome. I did not know that. So, it sounds like you were able to balance the two academics and sports pretty well.

Joel Sattgast: Tried to. There were times that it did not work well. And, you know, what we know now about some of the the various factors that play into injury as it relates to kind of the ecosystem model, that probably was a was a catalyst for some of the times that I was sidelined. Some of them were macro traumatic. I left college with several more concussions that I probably didn't necessarily need having played soccer.

I also had soft tissue injuries, tendon issues. I don't think, knock on wood, there were any bone stress injuries in there. But at the same time, that doesn't mean that they didn't occur and I just didn't see them or other providers didn't see them. So, you know, that idea of balance, maybe, maybe I struck it, maybe I didn't, maybe, you know, trying to do so much was a catalyst to some compromised musculoskeletal health. I don't know.

But it definitely was a fun experience and definitely something that if you get the chance, if anybody has the opportunity to do that, would encourage them to take the leap.

Jimmy: Yeah, that's funny. We had same path but slightly different mindsets going in. When I was a kid, all I cared about was athletics. And so for me, was like running was my ticket to go to school. I didn't really care about where I went, I just wanted to continue to run.

Fortunately, like my brain evolved and I started to take academics a little bit more seriously. Yeah.

Joel Sattgast: But yeah. What just out of curiosity, Jimmy, what what distances did you did you target or compete in?

Jimmy: I was a five k 10 k runner.

Joel Sattgast: Oh, okay.

Jimmy: Yeah. Yeah. So long stuff. In high school, was more 800 meter runner, thought that didn't want to run fast or longer than that. And then first year in college bumped up to the mile and five ks.

I remember freshman year running a five ks indoors and yeah, then that was it after that. Brutal. What were your events?

Joel Sattgast: When I was in high school, I predominantly did the 404 by four mixed medley relay. And then similarly got to college. Everybody bumped up for the most part unless you were like elite level. And I was I was good, but I wasn't elite. So I became an 800 meter runner and then did DMR, did the four by eight.

And that first year was just brutal. You'd go through your first lap of the 800 and be like, I'm done. Nope. You got to do it all over again. It was a very humbling experience, but one that definitely stretched me and one I look back on and I'm thankful for it.

Jimmy: So then after school, when did you decide like PT was something you wanted to pursue? Interestingly enough,

Joel Sattgast: PT was a decision I came to later. I was pretty much hell bent on pursuing a medical career. I was really fortunate that the sports med doc at the university was willing to let me kind of come into the OR with him. And so I went into the OR probably probably for almost two years straight, sophomore and junior year. Every week I joined him in the OR and really great guy.

And it just confirmed that that was kind of the trajectory I wanted to kind of go on. And then one day he said, Well, you joined me in the OR, but you never joined me in the clinic. Why don't you come in and see kind of clinical care? I was like, Oh, that's a good point. And I went in and from essentially 7AM until noon, so kind of his morning rounds, he saw over 30 patients.

Jimmy: Oh my God.

Joel Sattgast: And I kind of sat there and he would go into a room I'd kind of follow him in. He'd come out. He'd pick up a phone. He'd dictate into the phone, maybe a two to three minute note, right? He'd hang up the phone, then he'd into the next room.

He'd come out. I think he took one restroom break the entire morning, pounded a couple of mugs of coffee and just boom, boom, boom, boom, boom. And I asked him, I said, is this a pretty typical day for you in the clinic? And he goes, oh, yeah, I got to see all my patients that I've either had clinical care with or post op follow ups or anything like that because in the afternoon I'm at the university, so I can't see him then. And he was working sixty to sixty five hours a week, pulling these really long days on days that he'd be in the OR.

He'd be in there at 5AM. Right? And I joined him at six, but he would have already been there for a period of time. So I started chatting with him a little bit and it got me thinking like, is this the model of care that I want to deliver? Is this the type of profession I want to go into where I feel like I'm always under the pressure of the clock to see more patients, to expand my day, so on and so forth?

And by the way, it's not like he was new to practice. This was twenty years into clinical practice. Uh-huh. He was a partner in the practice. It wasn't like he was trying to make his way and climb the ladder.

Like, this was just his job. Now, is there an argument that there's other opportunities within orthopedic practice, within medicine to have more balance? Yeah, probably. And he may have preferred that. But I had a little bit of a crisis of conscience at that point.

And I was like, you know, I don't know if this is exactly what I want to do. And it just so happened that there were some other things that were going on personally. Failed relationship, for example, in college, a few other things. And pretty much I had an anxiety attack. The only time that I can really kind of say, yep, that was an anxiety attack or panic attack.

And because of that, I ended up saying, okay, I'm going to take a year off. I'm not going to pursue going towards med school, which I kind of felt pretty stupid about doing because I'd already taken the MCAT and interviewed and all this process. But I pressed pause. I was going to go to the University of South Dakota med school. That's where I grew up.

Press pause and said, okay, I'm going take a year off. And I worked in biotech sales. And I thought, okay, during this year, I'm going to check out other areas of medicine. Maybe it wasn't just ortho, maybe there's something else in medicine, like maybe cardiothoracic or, maybe just general primary care. So I started shadowing a whole bunch of folks as I had time when I wasn't working the sales job.

And over time, I realized I don't really love any of these medical professions. Any of the disciplines, I mean, they're cool. Cardiothoracic surgery was really cool to observe. My uncle is an optometrist, so I shadowed that. Ultimately, I ended up making my way to physical therapy and chatting with some of the folks that I was kind of job shadowing and just kind of observing day to day clinical practice, I realized this is a better fit for who I am from a personality standpoint, for the long term kind of career trajectory I would hope for in terms of time, the ability to still have a family, be present in their lives, still have some leisure time outside of the clinic, not feel like, you know, I worked sixty hours and now I'm just trying to recover over the weekend before I do it all over again.

So that idea of kind of looking across multiple domains of lifestyle and trying to figure out what was going to be the best fit, that seemed to most closely align to physical therapy. And so then I ended up pursuing that as career choice.

Jimmy: Wow. Yeah. I did not know that about you. So looking back, it seems, yeah, this one pivotal moment that sets you down a different path makes me think about how many people kind of stay on the path and it's not until after the fact they're practicing, they're in a career that is not a good fit And now they're trying to figure out what to do. Because I feel like you see that a lot nowadays, especially in medicine.

Joel Sattgast: All the time. All the time. And you know, there's this idea of, for lack of a better term, like kind of this sunk cost notion or sunk cost fallacy, right? I've invested so much time and effort into this. I need to see it through to fruition.

Jimmy: Yeah.

Joel Sattgast: But in actuality, alright, that year off in between, yeah, I could have been pursuing something. But if you think about your career trajectory, right, you're going to be in a a career for anywhere from twenty five, thirty, forty years perhaps.

Jimmy: Mhmm.

Joel Sattgast: Taking a momentary pause of a year or two to really discern where it is you're going, how it's going to be that you get there, what impacts that's going to have on your life, that pales in comparison. That's not even 5% of your career in terms of length of time, right? Duration. And yet it has a profound impact on where you're going. And I think you're spot on.

A lot of folks across the disciplines, whether I'm working with students in the in educational setting, whether you're working with patients in the clinic, whether you're coaching folks, we tend to kind of put blinders on when we're making decisions and take a myopic approach and only see what's directly in front of us and then make the decisions in that capacity rather than zooming out and saying, Well, what effect does this decision have over the broader expanse of time? You know, I know one area that is easy to think about is in the space of coaching. And one of the things that I'll commonly say to folks when they're debating, do I have a race? Do I not have a race? I'm dealing with this niggle.

Do I even pull out like a did not finish a DNF? Heaven forbid that you do that. But at the same time, there's always another start line. And if you make a hasty decision in the moment that is kind of spurred on or influenced by emotion, by panic, by anxiety, fear, you're probably going to make the wrong decision. Yeah.

And the consequences of that, they could be either immediate or they could be lifelong. You don't necessarily know. So pressing pause and taking that opportunity to really discern the decision in front of you, I think you're spot on. I think far too many people either lack a little bit of that ability to discern or perhaps lack the capacity or have people in their lives that can help them almost like save themselves from making that decision.

Jimmy: Yeah. It's sometimes I call it like self sabotage. It's you much your head in the sand, try not to look at it or in that coaching context that you just described where made me think of an athlete I'm coaching right now who's got a big race coming up and three weeks out starts getting an illness and is debating like, do I keep training through this? What's the deal? Like I need to do this last long run, trying to hold him back and convince him that like, you're just going to dig yourself in the hole.

And here he is two weeks later, still in that hole, the race is a week out because he tried to force things instead of this is like a very small case of like what you described, but the way you describe it Joel, like you're very thoughtful. And even at a young age, like going into college, you're very thoughtful. Coming out of college, very thoughtful, like thinking about things. Where did that skill develop?

Joel Sattgast: That skill developed at a at a pretty young age, mostly because both of my parents were pretty actively involved in in our childhood. I kind of frequently say I hit the jackpot in that regards. And this is maybe more front of mind because I just lost my dad this last year, this this last summer. But one of the things that he would he would commonly say when we would make poor decisions, which was frequently growing up, is he had this line. He would say, I hope it was worth it.

And I'll give you an example. So so one time, I have two siblings, and one time my brother and I were kind of in a little bit of a argument with my sister. And she went in her room, shut the door. And I don't remember our ages. I think maybe we were like nine and 12 or something like that.

My brother's a little older than I am. But we thought, you know, we could get my sister to come out of a room if we made some kind of commotion that she'd have to open the door to investigate. July 4 had just hit. So we had leftover firecrackers and like cherry bombs and stuff. So we investigated.

Oh, you know, if we reinforce a milk jug, we could drop the firecrackers in the milk jug and then set it outside of her door, inside of our house, mind you. Right? So we did this. We tested it outside. You know, that whole idea of having a hypothesis, testing it, right?

Started at a young age. So we dropped these in a milk jug, set it outside of her bedroom door. But what we failed to consider was that material properties, right? The idea of stress and strain and creep were occurring with our tests. And so when we set the milk jug outside of her door, even though we had reinforced it with duct tape, when we set the firecrackers off, this was now the third time that that had happened.

And it obliterated the milk jug and left this huge burn mark on the the carpet that my parents had just replaced. Oh, no. So, obviously, parents not happy, not pleased. My dad's comment was I hope it was worth it. Amazing.

You know, that happened so many times throughout my childhood. And it it really instilled this idea of, alright, think about the consequences of your decisions. Right? I hope it was worth it. Yeah.

Does the does the consequence, does the outcome make the decision worth it? And many times growing up, no. No. Like, I made very poor decisions. And that instilled it from a from a pretty young age.

Among other things, there were other personal life experiences that maybe forced me to, I don't know, grow up or mature maybe a little a little faster. But that idea of I hope it was worth it. Thinking back, reflecting back and really figuring out was the decision that I made now at the point of conclusion, was it worth it? And in some cases, was. In other cases, it wasn't.

But part of that process was essentially using a legal pad and making a line down the middle. This was a lesson that my dad taught me in in high school. And you would essentially make a pros and cons list.

Jimmy: Mhmm.

Joel Sattgast: And you would journal out and say, okay, what are all the pros of this decision? What are all the cons of this decision? And I remember over the years, I would fill pages when I was trying to make a decision, whether it be related to college, whether it be related to life decisions like ultimately getting married, where I went to school for grad school, those types of things. And every time I've done that, I've had a lot more peace about the decision that I ended up making because I could go into it with clarity and transparency to say, All right, I haven't made this rationally. I haven't made it quickly.

Rather, I've weighed kind of the various components that are influencing this. Because of that, now I can make the decision and I can move on. I can own that decision. I don't have to play the what if game or anything like that. And again, that that came from a pretty young age.

Jimmy: Yeah. I love it. Sounds like you're going to make a great dad if you take half of these skills with you to, yeah, to your I role as a hope so.

Joel Sattgast: I will tell you, one of the hardest things that I do and I think you may relate to this, from past conversations. One of the hardest things I do is put on the hat of dad. That is arguably one of, if not the most humbling roles and vocations that I have.

Jimmy: Yeah, a 100. And it's, as challenging it as it is, it's also very rewarding and probably the best part of my life.

Joel Sattgast: Yeah, very much so. I agree with that, 100%.

Jimmy: This reflective skill that was instilled in you from early age led you finally to pursue your career in physical therapy, which is, yeah, so it's kind of a different story than most people were. Like for me, getting injured as an athlete was the thing that kind of exposed me to physical therapy and got me through or got me into there. So once you got, once you started on that path towards getting a degree in physical therapy, how did how did life unfold from there?

Joel Sattgast: Yeah, good question. PT school was a lot of fun. I went to school at, Creighton University in Omaha, Nebraska. And part of the reason why PT school is fun is I had a really good group of individuals that I spent time with, still good friends to this day. And that whole idea of iron sharpening iron, that was very much the case in PT school.

So, we complemented each other, we were able to hold each other accountable, and it was a rich learning environment. Creighton at that time also had some of the pretty significant thought leaders, if you were, in the profession. And so I was very fortunate to count some of them as mentors and advisors, and to be able to learn from them. And that proved to be a pretty decisive thing getting into education. And we can talk about that if you want.

But some of those individuals like Judy Gale and Gail Jensen, Gail Jensen is a pillar within physical therapy. She's published just immeasurable amounts on educational theory and pedagogy and things along those lines. And I got to learn from her at Creighton. So that a huge win in my book, if you will. And then what was interesting is right after PT school and really throughout PT school for the three years, I was pursuing military service.

So my dad was a Navy veteran. My grandpa was an Army veteran. I have multiple uncles that were Army Air Force, so on and so forth. And in all actuality, that whole pros and cons piece, I was actually going to go into the Marine Corps coming out of high school. Nineeleven had just happened.

A whole bunch of my my buddies, were going to enlist, but I graduated high school at the age of 17. And so I needed my parents to sign off on my enlistment and, they wouldn't sign off. They're like, we want you to do one year of of college and if you decide after that that you want to go into the to the military grid, go for it. But do one year of college. They wouldn't sign off on the enlistment.

So that's why I ended up going to college as far as not pursuing kind of military service. And that, you know, kudos to them, that proved to be pretty transformative because they knew once I started college, I wasn't going to quit. Right. But I still wanted to serve and part of that was familial history, but part of that was also kind of a bigger than self duty to country ability to help kind of altruistic idea or attitude. So throughout PT school, I'd been applying and the Air Force was kind of the area that I wanted to pursue.

They have a pretty good model of practice for the Biomedical Corps. And it just so happened that my uncle was also in the Air Force and could give me some advice as far as what that looked like. So I was pursuing that about a week before graduation. I found out that I'd been selected, which at that point, there were only four PTs that were selected nationally that year to kind of matriculate into the Air Force. So I was pretty excited.

And in July, I was going to go to officer training. And two weeks before officer training, I was diagnosed with metastatic cancer. And so, I ended up getting medically discharged from the Air Force and thus began a year and a half process of kind of going through multiple surgeries and scans and treatment and all that kind of stuff. Thankfully, I've been in remission for over a decade. So, I feel very, very fortunate in that regards.

But my career trajectory, PT school then into the career straight away, right out the gates looked very, very different.

Jimmy: Yeah. So you were diagnosed right when you were graduating. How old were you?

Joel Sattgast: So let's see, I would have been 26.

Jimmy: Yeah. So just a baby, yeah. Yeah. Man, what was that like?

Joel Sattgast: It was horrible. Absolutely the low point of my life, which was really interesting because I was coming off of this pinnacle. Yeah. And then just the floor, you know, gave out and came crashing down. I would argue I was probably in some of the best physical condition that I'd ever been in.

I just run a marathon, was planning on a few multi sport type events that summer. No kids yet. So, you know, there was a little bit more freedom in terms of time, things like that. I was super excited to go into the Air Force. First duty station, if you will, was at, Nellis Air Force Base in Nevada, which was a really cool area.

So we were excited for that. And then all of it just stopped. And it was really interesting. I had completely forgotten about this. I had crashed my bike and taken some skin off my knee.

And essentially the scar tissue that came back looked kind of funny. It had a weird pigmentation to it. And if I bumped it occasionally, it would start bleeding. And I thought, that's weird, right?

Jimmy: Well,

Joel Sattgast: my wife's side of the family is all doctors and surgeons and things like that. And so one of them, I'm a poor grad student at this point. One of them over Thanksgiving earlier that year had said, come into the clinic, we'll biopsy, take it off, and make sure nothing else is going on. So this would have been, you know, several months prior. And I didn't hear anything from him.

And so my wife and I just kind of moved on with life, did clinical rotations, got ready for graduation, so on and so forth. Well, unbeknownst to me in the background, this sample that was biopsied was bouncing from lab to lab. And essentially nobody could figure out what it was. Yeah. So, it was in Michigan for a little bit.

Michigan, I think it was at the Mayo Clinic for a little bit possibly. And then it came all the way out to California. At the time, University of California San Francisco had a world leading dermatopathology lab. And so they sent the sample there to try to figure out like what is this? And they ended up doing a genomic hybridization of the sample.

So they essentially sequenced my DNA and they saw an upregulation and a downregulation in two genes. And the only time that that happens is in melanoma, essentially unregulated melanocytic proliferation, right? And there's a subcategory of melanoma. I didn't know this. I thought melanoma was strictly sun related.

Jimmy: Sure.

Joel Sattgast: But at the same time, there's a subcategory of melanoma that it's unregulated cell division. Now that can happen from exposure to the sun. You damage the skin, the sun is the catalyst, and then that's where that goes. But it can also happen in cases of scar tissue formation and healing after significant tissue trauma. And that was my side of it.

And it's not super common, but that was the catalyst. So I was really fortunate. My wife's from Michigan and some of her family medical wise had some contacts at the University of Michigan Comprehensive Cancer Center. And so, I was able to get in there right away. I ended up having a total of four surgeries, follow-up care, treatment, scans, immunotherapy, those types of things.

And even with it being metastatic, which melanoma does not have a good outcome if it's metastatic, I was very fortunate that care was good, treatment was good, and, like I said, I've been in remission for over a decade, so.

Jimmy: How long was that process of like you dealing with treatment?

Joel Sattgast: Yeah, it was just over a year. It was about fourteen or fifteen months. Because essentially what would happen is they would do a surgery, then you'd have to wait. So like, they'll do a sentinel lymph node biopsy to see, okay, is it in the lymph nodes? And that came back, yep, it's in the lymph nodes.

So then that automatically means you have another surgery, right? And then there would be a surgery for what they call wide excision. So where they took that initial biopsy, they have to go back in and they have to essentially take clean margins so they expand the area. So, one of the surgeries, they essentially took so it's on my knee, right? They essentially took all the skin from the top of my knee and then did essentially kind of like a skin graft and sewed things back together.

And so I have a pretty gnarly scar on top of my knee. But through that process, you can't bend the knee or anything like that, right? You'll rip the sutures. So you end up essentially in a long leg brace for a period of six to eight weeks while that's healing. So then you have to wait for that to be done before they can do the next surgery.

And then because it was in the lymph nodes, they took all the lymph nodes out of my right leg. So, it's called a lymphadenectomy. And so, then that was part of the process. And then you have immunotherapy and things like that, which is, it's kind of like chemo, but it's essentially you're trying to bolster your immune system to go after any cancer cells. And that essentially means you get to self inject yourself daily for several months and you end up with the flu.

Jimmy: Man, yeah, just, just what you wanted. Graduating from PT school, yeah, ready to rip and roll. Yeah. So I'm guessing that you spent whatever fifteen, sixteen months like life on pause. This is the focus.

What was it like coming out of that?

Joel Sattgast: Frustrating, mostly because I knew the Air Force was off the table at that point. And there was a lot of bitterness and frustration. It wasn't an easy process to get into the Air Force and then to have that essentially taken away. Yeah. I was not happy, we'll put it that way.

To try to kind of keep myself busy, I had started working at Wayne State University in Michigan and working in a clinical capacity. So I was only off of work, if you will, for about six months. And then kind of concurrently to continuing to receive care and treatment and scans and all that, I started working, trying to like more or less distract myself. I mean, that it was a coping mechanism. What was interesting about that is because it was affiliated with the university, there was a little bit of an exposure there to, to dip my toes in the water of education.

And so I was able to start adjuncting a little bit. And then also, I was in a department there called PM and R, Physical Medicine and Rehabilitation. And there were other medical providers in that department. It's kind of an interdisciplinary department. But then there were also residency folks that were associated with that.

So folks that were in a PM and R residency were within our department, and they needed somebody to teach these PM and R residents about PT related topics that weren't just PT. So like, for example, functional capacity evaluations or assessments, right? FCEs or A's, chronic pain related to lumbar spine, or possibly return to run, right? Things along those lines. And they asked me if I wanted to do that.

And I said, I don't know. I've never taught before. Like, I do a little bit of adjuncting, but sure, I'll take a stab at it. And it was actually that experience that kind of started to peak my interest into education. And had it not been for that, I don't know, things could have looked differently in terms of the long term trajectory, so.

Jimmy: That's pretty fortunate. How How long did you stay there and how long did you teach in that role?

Joel Sattgast: Yeah, good question. I was there for two years and then a good friend of mine, who's actually in the state of Washington, has a clinic, asked if I'd be willing to work with him in clinical practice. And so I ended up pressing pause on that because I was here again, this whole idea of reflection and kind of making different decisions and things like that, I was torn. I really had kind of like two career paths. I could either go the route of kind of continuing to pursue this opportunity at Wayne State, which was kind of a mix of clinical practice, but also education.

Or I could kind of take this career path, which was clinical practice in an orthopedic setting, and possibly even pursue kind of long term like business ownership. And so I opted to kind of explore this path over here because I hadn't really explored it. And so for a little over two years, practiced in Western Washington and it was a great opportunity. I really enjoyed it. The people I worked with were fantastic, but essentially I learned that we were better friends than kind of future business partners and colleagues.

And so, ended up stepping away from that practice. And it just so happened at that time that there was another opportunity in education. And so I ended up pursuing that opportunity and that kind of led to where things are now essentially.

Jimmy: So your interest got peaked early on right after graduating with that experience.

Jimmy: I'd like to take a moment to thank our sponsor Runeasi. Runeasi is a running and jumping analysis tool that helps provide objective data on things like impact loading, dynamic stability and symmetry. I've been using it in the clinic for the past three years and I love how easy it is to add to my evaluations. Not only that, but it backs up my clinical reasoning and helps me with my decision making process when I'm doing exercise prescription. So if you're a physical therapist or running coach, head on over to runeasi.ai, book a demo.

If you're lucky, it will be with me.

Jimmy: What city did you move to in Washington?

Joel Sattgast: So I was in Whatcom County, which is kind of a mix of a variety of locations. Bellingham is in Whatcom County, Linden, Ferndale. We lived a little bit north of Bellingham and Beautiful. For folks that that have never been to like Northwest Washington, it's a it's a bucket list. You absolutely have to go.

And in particular, I'm I'm pointing out Whatcom County, not just like Bellingham or Ferndale or or Linden or Knooksack or kind of these little communities, but the the county on the whole. It's it is stunning. You're right up against the North Cascades. You have access to the water. The Bay is right there.

There's a little area called Birch Bay. It's absolutely gorgeous. And world class mountain biking, cycling, running. There's these little kind of foothills called the Chuckanuts right in there. It's just amazing.

So part of what influenced that decision was not only the clinic, but also the location. I mean, was amazing.

Jimmy: And then what was the clinical population like that you were working with?

Joel Sattgast: All orthopedics. But what was interesting was we were less than 10 miles from the Canadian border. And so we saw folks, not only within The US healthcare system, but also the Canadian system. And because of kind of that back and forth, there was a unique element to the business practice. But then also because of the community that we were part of, there was a heavy emphasis on sports.

And so that really kind of catalyzed my interest in terms of the fact that I wanted to work with runners, I wanted to work with cyclists, I wanted to work with this endurance population of which there was no shortage within that area. And it just so happened at that time that there was a group of guys that would ride every single morning. It was called the five eleven group because they met at 5AM and we would ride, for several hours before work. We'd shoot out to Birch Bay, loop through the state park there and then come back. And that was that was a formative time.

I really enjoyed that group of guys, really enjoyed kind of, again, that idea of iron sharpening iron from a fitness, but also from a personal standpoint. Very, very solid individuals. And it was hard to leave that area. It was hard to leave that practice, hard to leave those friendships. But at the same time, I was sensing that clinical practice was really important to me, but this opportunity to return to education was something that would really kind of complement the bigger, long term trajectory that I had.

Jimmy: Yeah, so what was pulling you there? What was the drive, the motivation for you?

Joel Sattgast: So it's interesting. Clinical practice is something that I still do. I think folks sometimes see clinical practice versus academics or education as like a binary decision or like there's a dichotomy there. And I think they're really, really complementary. They work together.

And so, my decision to kind of step into academics and education was not so much at the expense of clinical practice as it was to complement clinical practice. And so there two major influencing decisions there. One was we took a lot of students at the clinic that I worked at. And a lot of students would get into their last kind of bout of clinical rotations. And I was realizing, man, there's a whole lot that is not either being taught well or not being addressed in curriculum within PT programs.

And I would talk to then the DCEs, the Director of Clinical Educations, right? Because we'd have these midterm phone calls, final phone calls to kind of talk through things. And I would ask questions. They'd say, Hey, you know, is this part of the curriculum? No, we don't do that.

Is this part of the curriculum? No, we don't do that. I'm sitting here scratching my head going, Man, I feel like this is such a crucial part to clinical practice. Why is this not part of the curriculum in PT schools?

Jimmy: What were some of the major gaps that you saw?

Joel Sattgast: I didn't know it at the time, because I hadn't really been well versed in educational development and pedagogy, right? But there's kind of these three parts to education. There's the explicit curriculum, the implicit curriculum, and then the null curriculum. And a lot of programs focus heavily on the explicit curriculum because that's the way in which you pass the NPTE. So they focus on concepts, differential diagnosis, and heavy emphasis on psychomotor skills, right?

Because you got to be prepared for clinical practice. But then what's missing are what sometimes we call the soft skills, but those sit or fit within the effective domain. They're the pieces that are how you interact with folks, right? And some programs have these only because essentially CAPD, the accrediting body, says you have to have something, but they don't integrate it into the curriculum. So students kind of blow it off as, well, this is an annoying class.

It's a one credit element. I'm not really going to pay attention there or it's just not taught at all. So elements of psychosocial care, elements of ecosystem care, a lot of programs that were sending students to our clinic really didn't have that emphasis outside of a professional seminar series or a one credit class. And so either students weren't getting the skills necessary or they weren't integrating the skills into a broader perspective, right? It wasn't so much that students were unsafe.

They, you know, they knew how to do mobilization. They knew how to apply, let's say, like a basic exercise physiology principle, frequency, intensity, time and type, those types of things, right? But what they were lacking was seeing the bigger picture. So that's the second part, clinical reasoning. And then they were lacking the soft skills, the patient interaction pieces.

So we would, we being clinicians and CIs, we would spend really an inordinate amount of time trying to bring folks up to speed in terms of how do you interact with a patient, right? They're not this robot that you can just kind of very quickly rush through the progression of care with and give a couple exercises and expect things are going to go perfectly, right? It's very much kind of a dance where sometimes you're leading as the clinician, sometimes the patient is leading. And that's something that takes a long time to develop. I don't expect academic programs to be able to do that in a perfect way, right?

You need reps to be able to see that come to fruition. But the fact that it wasn't being addressed well kind of got my wheels spinning to say, all right, I've had one exposure to the academic piece back in Michigan at Wayne State. Not, I wonder if I could do it better, because I didn't think I necessarily could do it better, but I wonder if there's complement my clinical practice experience within the education realm. Is there a way in which these areas could complement each other? And so that kind of piqued my interest and that's one of the big reasons why I went back into academics.

Jimmy: Yeah, no, I love it because even still I'm thinking about clinically with patients I work with, it's how do you like I've been a PT for twelve years now and may it will be twelve years and I feel like you learn the skills, you learn how to diagnose, you learn, yeah, like how to treat or how to recognize a bone stress injury, how to do all this stuff. But then the challenge, how to prescribe exercise. The challenge then becomes how do you build that therapeutic alliance, gain the patient's trust, get buy into what you're doing, the plan that you create with them, create it together. And even twelve years out and I feel like I started trying to work on this from day one, I'm still learning, it's still a hard thing to do. Every patient is so different.

Every patient kind of responds to things differently. So it's awesome to hear that that's kind of what brought you over there to kind of blend those two skills because I would say for me in PT school, man, they didn't talk about that at all. That was, there was nothing about that. And what was weird for me upon graduating, it made me swing very far over to that pain science world because it was to me at that time, it was like the answer to try to help develop those soft skills. But then, and it was at a time where I think in the PT profession we were kind of swinging that way anyway, but then it didn't really answer the question.

So yeah, I'd love to hear as you started in academia, how you were able to yeah. Were you successful with bridging that gap and bringing it into the university?

Joel Sattgast: Initially, no. Because you don't know what you don't know, right? It was it was an acculturation process and I would say a shock. I'm stepping into the university. I probably came in with rose colored glasses.

And as with most things, you step into it and you think, I'm gonna I'm gonna change all the these dynamics. Right? And I'm gonna I'm gonna have immediate success. And we know that's not true. That being said, it it took a while, but I've now been in academics in a in a full time capacity.

This is this is my ninth year. And I would like to think that I'm getting better at it. I would like to think that I'm getting better at the refinement process of understanding maybe what levers to play with and and, you know, what dials to maybe turn up or turn down, those types of things. But, yeah, initially it was it was a challenge. And and part of that again is is that acculturation process.

You're not working in a silo. You're not working in a vacuum. You have to work in in the department. You have to work in the broader university. Learning the the university system, it was very foreign.

We don't go to school to to be educators, for example, explicitly. I think we do implicitly, that might be a thread to to pull on in a second. So that was interesting to kind of learn all that. The other piece, though, that was was interesting, if you will, was figuring out how to interact with students in that professor student relationship role. Because again, I had been in that in an adjunct capacity and in a professional setting with that residency program at Wayne State.

But I hadn't been in a primary professorial educator role. And so figuring that out initially was interesting. The first year went okay. The second year, I call it my sophomore slump. It definitely was a growth period for me.

But I think one of the ways that I've been able to find success, and actually a few of the ways. Number one is I haven't stopped practicing clinically. I know that this is getting better in academics, but there for a while, and it may even be persistent at other universities, I can't speak to that. But there for a while, it seemed that a lot of folks that were within academics, it became all consuming and they walked away from the clinic. And so you would have folks that were teaching a concept of clinical care, but they hadn't seen a patient in over two decades.

And you sit there and you kind of scratch your head and you're going, Man, help me understand how it is that you're providing this contemporary evidence based idea of clinical practice and care. And yet you're not on the front lines. You're not in the trenches. You're not seeing how this actually works on daily basis, if you will.

Jimmy: So it's one thing to have the knowledge and know the answer. It's another thing to transfer it to somebody else and to get them on board with it. Think spot on. I had a coaching client today that I was sending an email to because he was in here yesterday trying to get him to back off of some of his strength training because he's going nuts in the gym and he's doing a ton and trying to convince him that he probably what he probably only needs is four exercises, super low volume so that he can it supports what he does out there. And this is supported by like my mentors in the strength training world and the literature there.

But being able to convince him and get him to say, oh, that makes sense, I'm going to do that, has can be really challenging. It's like, I know what I want him to do, but it's conveying it to him and getting him to accept it and understand is can be a huge challenge. The same thing applies to the PT world and I'm sure teaching.

Joel Sattgast: Absolutely. It's messy, right? So you have this concept and this is what's interesting. And this is why I say it complements itself so nicely. Whether I'm in academics and kind of that educational model classroom, whether I'm in the clinic or whether I'm coaching clients from a performance standpoint, it's messy in all those areas.

I have a concept that I want to convey to students, right? So case in point, tomorrow we start to foot foot and ankle. We're wrapping up the lower extremity. It's the end of the second semester, right? So I have this concept that I want to help them understand this domain, right?

And on paper, let's say that we're looking at the differential diagnosis of, I don't know, pick one of the major foot and ankle running areas, right? Achilles tendinopathy, plantar fasciopathy. Okay. So I want to convey something to them. And on paper, it looks like, Okay, if I just do these things in the history, if I take a really good history, ask these questions.

I asked about volume and exposure to intensity. And then I do these tests and measures. They're more painful at the insertion of the Achilles versus more in the muscular tendinous junction within two centimeters of the Achilles tubercle. Okay. That has to be an insertional tendinopathy because that's where their pain is.

And then I'm going to do X, Y interventional approach and they're going to get better. Like tick, tick, tick, tick, tick, tick, right? Standardized. Standardized. That's not clinical care.

Because the piece that you're missing is whoever that patient is. Oh, by the way, they're not just running. They're on their feet for an eight hour shift. And how do you mitigate that? And, oh, by the way, not only that, but they're a mom or a dad and they have three or four kids.

And so they're managing all of those sports and activities on the weekend. So, you know, carving out this dedicated time to come in for therapy is somewhat challenging. And so sometimes it is addition by subtraction, to your point, with your client. It's not, Oh, I got to find the perfect exercise. It's not, Oh, I have to go and look at the latest systematic review from British Journal of Sports Medicine.

Or if it's plantar fasciopathy, I got to go read the Raffleth article on high load exposure, so on and so forth. What can I get Jimmy or Susie or whoever to do consistently? And that's probably two to three things. Yeah. And that's the messy part of clinical care.

So I can lecture on the pie in the sky and the latest evidence and what has the best overall incidence and prevalence and clinical care ratios and so on and so forth. But translating that into clinical care is oftentimes the piece that's missed in the academics. And so then students do get out and they feel lied to. Right? My professors told me it was this.

Now I get into clinical care and it's not this. And that doesn't even pull in the fact that you might be seeing patients on a forty minute time slot. And so trying to get all this done in a very concentrated period of time is somewhat challenging. Yeah. So kind of going back to your question of how has it been making that transition and how successful have I been?

I think one of the strengths that I have is my job is not to create, you know, this idealized PT. I don't do any of that. Rather, it's to set up an environment. It's to create an interest. It is to kind of cultivate, if you will, this spark of interest in an area.

And that happens in students. And then to help them see breadth and depth of the profession that they're walking into. Yeah. And that way, they can go in eyes wide open. That way, they can then decide, all right, I really like this, but this is something I'm going to have to deal with.

Because ultimately, a lot of students In fact, we just went through the process of accepting our incoming class, right? A lot of students will say, Oh, I'm really passionate for physical therapy. I'm really passionate. I want to help people, so on and so forth. And then by time they get to their second and third year of of the program, they're saying, I feel burned out.

Yeah. I feel like I don't want to continue down this path. And if you stop and and you pull back a little bit, you're going, well, what happened to that passion at the very beginning? Well, that passion at the very beginning was probably obsessive passion. It was probably something that was short lived.

And they didn't they didn't know everything about the profession at that point. And so now where they're starting to feel burned out and they're starting to go, oh, I'm not interested in this. It's because they're starting to see things more transparently, more holistically, and they're going, this doesn't necessarily align with what I thought it was. At the same time though, if we can start to shift them from this obsessive passion to more of what we would call a harmonious passion

Jimmy: Mhmm.

Joel Sattgast: That's that's something that you don't come into PT school with. That's something that gets cultivated over a much longer period of time, but it's far more sustainable. And so that's probably where I see my role. My role is in cultivating that. My role is in supporting students.

Just like in the clinic when it comes to patients or just like in a coaching relationship, it's a partnership. It's not a hierarchy of a top down. It's not you've probably heard the term sage on a stage. It's not that. Like, that's not my role, right?

Rather, it's to come alongside students. It's to partner with them, to help them in a specific content area, musculoskeletal orthopedics, develop an awareness, a hunger for learning and then equip them with the skills that are going to help them be successful in clinical rotations and ultimately clinical practice.

Jimmy: Yeah, I love it. It's making me think about Dan John, the strength coach, I had him on the podcast last week and he talks about in his latest book, The Art of Coaching, that the term coach came from a carriage that would take you from where you are to where you want to go. And it's the coach's job, so us the coach or the teacher, to help you determine where you want to go and where you are and take you on that path. And so it's kind of like what you just described is really clarifying that messiness for the students and helping them understand that that's a real part of being a PT. And that idea of like the algorithm or the standardization of care, I can sympathize with that.

Like I remember graduating, having all my checklists, this is what I would do for this patient's eval, this kind of patient eval, this eval. And then you think it's going to be so black and white, but then it doesn't take long. A couple of patients in, you realize none of this is going according to plan. So you're there, you are now there as the teacher before they even get there to help show them that that's the reality. Spot on.

Joel Sattgast: And Jimmy, this is this is how we future proof the profession. Right? So so go back for a second. You mentioned all the checklists and things like that. Every student loves that.

Right? If I just do these things, I get the grade that I want. I can be certain of my performance, or I can be certain of the outcome when it comes to patient care. And right there, that's an area we have to press pause because we don't control the outcomes. Right?

We set the stage for them, but we don't necessarily control them. So we have to surrender that wanting of the outcome or control the outcome. But the other piece is going back to your to your idea of the checklist. We can create kind of a hierarchy or a heuristic of a if this, then that, and and create some of that pattern recognition. But guess what?

AI can do that too. AI is predicated on this. Right? It's it's algorithmically based of a if this, then that

Jimmy: Yeah.

Joel Sattgast: Seeing patterns. So if we want to future proof the profession and this is like all the rage right now, right? Of how do we how do we ensure that AI isn't going to take over our jobs? My brother-in-law works in IT, for example. And there is a huge component where these jobs are high level jobs.

They're employment that requires a bachelor's degrees and master's degrees and things like that. And people are being laid off because AI can do it better than them more or less. Right? Well, what's the thing that AI can't do? AI can't deal with that messiness, at least right now, that messiness of patient care.

AI can't deal with the messiness of coaching and, know, messiness kind of even has a negative con connotation, but but the the the challenge of the interpersonal communication. Yeah. Right. And there's any number of videos on on social media where it's interesting. You'll ask AI a question and they'll gaslight you.

Right? Or they'll say something that doesn't quite make sense. And so it just illustrates how important those people skills are. The ability to communicate effectively, the ability to be present in that environment when you're working with patients or clients. And ultimately, one of the things that you're doing within all of that, and this is why I think there's such a compliment between education, clinical care and coaching is you're teaching and you're learning, right?

Teaching is both happening from you to the patient, but the learning is from the patient to you. That's the teaching they're doing as well. So, a colleague, Matt Garber, says that, essentially, are two experts within every clinical encounter. Right? You're the expert in physical therapy.

The patient's the expert in themselves. And so within that to expert environment, you're teaching and learning. It's a back and forth, process. And I think you're spot on when you talk about the checklist. Checklists are good.

They help. But as you noted, what happens when you actually step into that arena or step into the ring and you start getting some punches thrown at you by patients, right? There's the old adage of, I think it was Mike Tyson that said, Everybody a plan until they get punched in the face, right? And the patient punches you in the face with something that you weren't expecting and all of a sudden you're going, well, I didn't have that on my list. What do I do now?

Jimmy: Yeah. And you mentioned this word uncertainty. And I think a lot of it stems from us, our discomfort with uncertainty, both clinicians but also the patients. They're coming to you to try to get some explanation and they want you to be certain. But there are, the whole medical system is surrounded by uncertainty.

And the thing about like, yeah, your cancer diagnosis, if we go all the way back to that, like the beginning of all that uncertainty at the beginning until they finally came up with what was going on. And that's probably more black and white than some of the MSK stuff that we see like chronic pain and things like this. And so I think the problem is that those the standardization or these checklists give us a false sense of security. And when that starts to fall apart, that's when I feel like people start getting burnt out and get frustrated with the profession.

Joel Sattgast: Yeah, very much is the case. And even even within the world of we're both in the running world, right? Take for example, a tendinopathy, right? For for all intents and purposes, tendons like load, they like tension, they need load and tension with regards to time and things like that, right? There's a whole body of evidence that also suggests that tendons also have a sensitization that's occurring.

And so it starts to kind of get into the pain science realm. And so it may not just be a capacity problem, it may be a sensitivity problem. And what happens when you're loading that tendon and you're doing all the load stuff right? You're grading the exposure and you're even using the right contraction type, right? You're moving from isometrics into concentrics, eccentric, so on and so forth.

And you're not getting the outcome that you want. Well, the literature would say, or Jill Cook would say, or Karn Silvernagle would say, such and such. And I'm using the pain monitoring model. You're looking for certainty and it doesn't always happen there. And sometimes you have to pull back.

Jimmy: Yeah. Because so maybe there's a malnutrition thing going on that's preventing healing from occurring. Maybe there's life loads that's preventing this thing from healing. And yeah, you can come up with the perfect rehab program, but you're not going to out rehab those things.

Joel Sattgast: No, you're not. No, you're not. And here again, you're not dropping that perfect rehab program into a perfect life. Right? Which is why that ecosystem approach is so important.

You're dropping it into a life that is being pulled in all these different directions. Coming full circle where we were talking about being parents and dads and things like that. One the greatest things that I've learned about my role as a parent is an appreciation for all of the other stresses and strains that happen in life. Early in my clinical career, I was kind of of the opinion of, Well, if you're not doing your home exercise program, like something's wrong with you. I gave this to you.

If you're not making time, like it's not important to you. When I get home in the evening and I'm done with work, like I'm on now as dad. Like I've taken off my hat at work. I put on my hat as dad. And that goes until they're in bed.

And then I might get fifteen, twenty minutes with my spouse and then I'm going to sleep. And it's like, okay, maybe I looked at that patient early on and I discredited all of those other life loads that were happening. And to your point, when I dropped that, that rehab protocol or program into their life, I was adding more. And if you don't subtract, more and more is not the solution.

Jimmy: It is not. Joel, I want to be respectful of your time. I know you have a hard stop here coming up. I feel like we have a lot more to cover. Maybe we should do a part two.

I would love to hear talk more about this ecosystem model you're describing, the lifeloads, how that impacts care and all of that. So maybe we'll get that on the books. But Sounds good. Listeners now to wrap up, where can people learn more about you?

Joel Sattgast: Obviously, most everything is online these days. If folks are interested on kind of the academic piece, they can look for Eastern Washington University that's easily accessible and there's a profile there. If folks want to reach out to me directly though, my clinical practice and coaching practice, it's called Trexo, PT and Performance. It's T R E X O. And certainly happy to continue any discussions offline, not only with yourself, but with listeners as well.

So if I can be a resource, feel free to reach out.

Jimmy: Awesome, Joel. Well, I wish I had you as a professor when I was going through PT school. So keep doing the good work and yeah, we'll talk soon.

Joel Sattgast: Sounds good. Thank you so much for the opportunity to chat, Jimmy. Appreciate it.

Jimmy: That's it for today on the Physio Insights podcast presented by Runeasi. Would you like to share an interesting case, insight, or have a thought about the podcast? Comment below, and don't forget to follow us for more episodes.