What's next.

A book about cauda equina syndrome!

Thanks for reading the 39th edition of my newsletter. This newsletter tracks my research as I write a book about lumbar radicular pain… and another one about cauda equina syndrome!

You might remember that a few months ago I mentioned that I was working with my friend Rob Tyer to make something for MSK clinicians on serious pathology. In this email I want to give you an update on our work. I'm really excited about it and I think we're making something you'll like.

How Rob and I ended up working on this together

I first met Rob when I was a physio student. As I mentioned on a previous newsletter, I knackered my back in the gym and got a radiculopathy and ended up booking a private appointment with him. To be honest, I partly chose to visit Rob rather than see anyone else or go through the NHS because I'd followed him on twitter for a while and the physio student in me just wanted to see how he practiced. I'm not sure I've ever told him that...

Anyway, a year or so later Rob came to our uni to give a lecture on clinical reasoning. His lecture made a deep impression on me. It was the first time I'd heard someone try to articulate what it's like to try to reason through complex clinical stuff. So often, people just said 'it's complicated' and left it at that; but Rob really tried to talk about what 'it's complicated' actually means and what mental tools to use to navigate that complexity.

After I graduated, I went to work in the same place as Rob, partly because, I must admit, I thought 'If this guy works there it can't be that bad'. As a new grad physio, I took a few unpaid hours every week to travel to Rob's clinic on the other side of town and watch him work and make notes...

Early this year, after I had finished writing my first sciatica book, I thought for a long time about whether I should just write the second one or focus on something different. I decided to focus on something different because that would help me avoid the trap of becoming too narrow in my thinking. I also decided that I needed to work with someone else. There's a saying about work, 'if you want to go fast, go alone; if you want to go far, go together'. I want to go far and create something of quality, something that will last.

The first person I thought of was Rob. As many people reading this might know, Rob has a particular interest in serious pathology and in particular CES. You might have seen him lecture on it at conferences. So I asked him if he wanted to work together to make something about serious pathology.

Since then, we've been meeting on Zoom twice a week for a few hours to talk shop. Rob tells me about cases from that week. I ask him questions about what I've been reading, and go away and read more about whatever we talk about.

Our approach to serious pathology for MSK clinicians

We quite quickly understood what sort of approach we wanted to take.

  • We wanted to come at the topic of serious pathology from a clinical reasoning standpoint. And we wanted the clinical reasoning to be how it happens in the real world, in real life. The clinical reasoning we learn about at uni is fine, but it's a kind of weird side-world, a collection of funny old theories and approaches preserved in aspic; it honestly feels like a museum to me. There's this huge literature on decision-making from psychology, economics, medicine, even poker that we don't hear about. And more importantly there's the kind of craft knowledge developed by people like Rob who have been on the shop floor for years.

  • We also wanted to make sure we approached the topic of serious pathology in a way that went beyond red flags. Red flags have come under some criticism lately as a concept, although we actually both like the concept a lot. The problem, we think, is what to do once you get past the red flags. Okay, so your patient has night pain: what's your follow up question? What's the follow-up question to that follow-up question? Okay, so your patient has certain features of CES but you're not sure if you should refer them to A&E. How are you going to make that decision? What do you tell the patient so things go as well as they can? What do you do if the person at A&E starts pushing back on your referral?

  • We also wanted to make sure we engaged with the psychological side of serious pathology for MSK clinicians. That sense that after a morning of tennis elbows and OA knees, all of a sudden someone has incontinence and radicular pain and the pressure is on. The fear of missing something but also the fear of being 'that clinician' who keeps escalating care unnecessarily. The nagging doubt that something isn't right but not knowing what it might be or how to fully reassure yourself or your patient. Making good decisions and being a good clinician is not a cold, purely rational practice; we are all creatures of emotion and those emotions influence our behaviour.

  • And we wanted to make sure we engaged with the communication side of things: how are you having these conversations? Are you really communicating clearly?

A very practical, useful (but never, ever boring) book

At first, we thought we were building a course. But the further we got with our discussions the more we felt like what we were actually doing was writing a book. And to keep the topic from sprawling endlessly, we decided to focus on just one kind of serious pathology for now: CES.

In the months prior, I had been making notes during our conversations and I turned those into building blocks for the draft. Then I re-wrote and re-worked it all and did a more thorough and systematic review of the literature. Now, we have a first draft done. At the moment we're going over the draft together and turning it into a second draft.

Our overriding aim in writing the book is to make it utterly, ruthlessly useful! It's going to be as short and punchy as possible (which is paradoxically harder to write than something long and expansive). It’s going to avoid theory and long lists of studies so that you don’t have to search through all that for the real guidance. It's going to skip over the very basics that everyone knows (you're already asking red flag questions every day...) to get straight to the stuff that will help you make better, more confident decisions in clinic.

I've got to say, I'm really happy with what we've got so far. Rob knows his stuff. And more importantly he spends a lot of time counseling and educating other clinicians, so he knows where people get stuck and how to un-stick them. I think our book is going to be one of the most useful clinical books out there. And don't worry I will do my best to make it readable and never, ever boring too.

Like I say, we're just at the start of a lot more work.

I’d love to hear what you’d like to see covered in our book on CES. Reply to this email to let me know.

Til next time,


P.S. Don't worry, Book 2 of the sciatica guide is also chugging along, slowly but surely!

P.P.S. The weather has finally become bearable in Houston so we’ve been enjoying spending more time outside. Here’s some photos I took at a nature reserve last week: