Decoding Laryngeal Mysteries & Elevating Pelvic Health

Dr. Frances Mei Hardin: Welcome to this week’s episode of Promising Young Surgeon. This week, Katherine Booker joins us to discuss her career as a physical therapist and coordinator of clinical education at her institution. Of course, I’m a huge believer in the importance of hearing from and learning about the journeys and expertise of medical professionals across various fields in the healthcare industry. And so, really excited to chat with Katherine and learn from her today. But before we jump into that discussion, I would first like to talk a little bit about something that I do in my daily life, in my ENT practice, which is globus sensation and chronic throat clearing. So, as I mentioned, you know, I’m a general ent. I see this a lot in clinic. This is part of my bread and butter, you know, laryngology practice. And the reason that I want to highlight it today is because in addition to the fact that I actually just love this topic, it’s because I like to highlight how much these diagnoses can be determined via, thorough clinical history. And so I was taught, I was trained, and therefore, I teach and train others, my junior residents, back in the day, and now my clinic team, to try and have at least a few working clinical diagnoses prior to even examining the patient based on story alone. And there’s something very algorithmic about this workup, which I find very beautiful. So, you know, I’m. I’m absolutely one of those doctors who says I do things the same way every time, and I do, like, you’ll see my set of questions, things like that. It is the same way every time I think, to my benefit and the thorough workups benefit.

Clinical history is critical to diagnosis of chronic throat clearing conditions

So let’s imagine a, 40 year old female presents to clinic with a three month history of globus sensation. In layman’s terms, that’s where it feels like something’s always stuck in her throat. She cannot seem to get rid of it, despite any amount of throat clearing, taking sips of water, etcetera. It just never really goes away. She did have Covid four months ago, and the cough did take quite a while to resolve. Certainly after that, like, it lasted several weeks longer than her coughs normally do. She does not endorse any known antecedent triggers, injuries or trauma. And so, okay, I’m not going to go into the whole patient visit and put everyone to sleep. That’s not really what we do on this show. But I will tell you a framework for the history taking portion of this workup. So, that’s all information that, let’s say, I got from the referral paperwork and from her visit with her PCP. So here’s what goes into my line of questioning. Well, I can tell you right now that the top three causes of globus sensation or chronic throat clearing in adults are one, post nasal drip, typically allergic rhinitis, although it could be, you know, vasomotor rhinitis or other causes of rhinitis. Number two, laryngopharyngeal reflux, which is also called, you know, heartburn, basically, where you can feel the acid come back up into your throat. Or three, cough variant asthma. And there are people who maybe didn’t even have asthma before, but as an adult, they independently developed this cough that could be a presentation of cough variant asthma in an adult. So that means that that basically informs the first three questions. Number one, any history of environmental allergies. We can always do things like consider allergy tested if there’s a question. Any history of reflux? Again, if called into question, there’s objective testing that exists, ph probe testing, things like that, that we can do to objectively evaluate yes or no. There are things such as silent reflux, which maybe we can get into on another day. Number three, any history of asthma? And even if they say, okay, well, no, there’s no history of asthma. And this person had a complete, exhaustive chronic throat clearing workup. Without an identified etiology, it’s not crazy to obtain like a set of pulmonary function tests or pfts to officially rule out cough variant asthma. Okay, so that’s that first little chunk of questioning. But then now we look at other interesting details about the history. So I ask any shoulder or cervical spine injuries, examine the medication list, look for any drying medications, like certainly people as we get older, but we’re still taking medications over the counter or prescribed that have anticholinergic side effects. Those are very drying, of course, we look for things like AcE inhibitors or arbs, you know, for their cough side effects. And then another huge, huge, huge question is, what’s your daily water intake and what’s your daily caffeine intake? So, you know, again, we don’t have time for the deep dive today, but I say this to kind of share, you know, some of these questions you may not automatically think of if you were thinking, it

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feels like something stuck in my throat all the time. Well, why am I asking about the, their cervical spine? I’m going to share just a couple times where clinical history cinches a diagnosis and is very critical to obtain. And not only that, but I’m going to give a couple examples where maybe this person even undergoes laryngoscopy in clinic, and it looks grossly normal. It looks okay. And so they’re just told, you look great. Get out of here, bud. And, you know, they’re kind of sent away. Like it’s a little unsatisfactory. And also, it hasn’t answered the question of what’s happening. So one example is, let’s say, like, in the woman in the example that I’ve shared today, she had a prolonged post Covid cough. Okay, well, months of coughing, that’s a risk factor for basically the equivalent of pulling a muscle in the front of your neck or pulling a laryngeal muscle from the anterior laryngeal musculature. And so something like that would be on my differential just based on that story. I had a woman, for instance, in her forties, who came in with this globus. No injuries, no trauma, no shoulder injuries, no c spine issues. But when I got to that last question, which I asked everyone about their water and caffeine intake, respectively, and then the balance between the two, she was drinking four large mountain dews per day and no water. And also she had had bronchitis several months ago, and the lingering cough never really went away after that. So guess what? We compensate until we don’t. And so what we recommend in terms of daily water intake is 60 to 80oz of water per day with matched increase for every ounce of caffeine. So, of course, in her case, she’s quite off from the mark. But often I’m counseling people. Hey, you know, you’re only at that 40, 50 ounce of water a day, mark, and then you’re doing a lot of coffee or soda on top of that. So let’s get you closer to our goals here. In the similar vein, I had a very, very nice gentleman, super active, very fit, in his seventies. So he was an avid hiker. You know, he was out every day. Like, he was really actually in excellent physical shape. But he came in with Globus. You know, of course, we do scope these people. So in all these scenarios picture, they get a scope, and there’s not anything actually growing there or sitting there or pooling there. So in that case, you know, I’m looking at his history, and I said, how much water do you drink? He was like, I don’t, And, you know, that that’s obviously never good. So I’m preparing myself mentally. I was like, oh, okay. You know, so. So what’s up? And he said, I only drink milk. Whole milk. It’s milk with all meals and milk for hydration in between meals. And again, getting his hydration reset and kind of weaning slightly off the milk and doing, like, a lot better hydration, that led to symptom improvement, you know, and again, in terms of the eye doesn’t see what the brain doesn’t know. So one of the things that was noticeable on his scope exam was just that the saliva he was making, it wasn’t purulent. It didn’t look like pus, it didn’t look infected, nothing like that. And again, nothing growing there, but it was much thicker. It was kind of like this viscous saliva that his body was making as opposed to, you know, really well hydrated and more fluid. Another quick example, this one is really huge, actually. I first saw it in 2020, where a whole run of people in their thirties and forties were coming in and they just had this chronic throat clearing, even if they didn’t get Covid that year. What’s so interesting is that what it came down to in many of these cases is that they actually the major change in their life. Well, in addition to Covid, the pandemic increased stress from that, certainly being at home, maybe with, you know, kids now at home from school, things like that. So certainly things like, acid reflux could worsen from stress. But their work setup changed. It was totally out of whack. So now, instead of going into the office, sitting at a work desk, in a work quality chair, you know, they were doing their work. Like some people said, well, I just sit at a bar stool, the counter in my home, which you have to think about positionally. That really did put those people out of whack. And one of the major contributors to their symptoms would be that they would have this cervicalgen and things like that. But again, they were sitting in a totally new, poorer posture every day and kind of like working from that standpoint. So those are all fixable things. But you do need to be thinking outside of just very little, very literal. Okay. You feel like something stuck there? I scoped you. I don’t see something stuck there. Okay.

The importance of a thorough history, of a thoughtful, clinical history

Well, there’s a lot that goes into the history and story surrounding these things. The last example that I wanted to share here, and honestly, it’s not. It’s not even related to this. It’s just such a good example of a principle that Katherine Booker and I have both said,

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you know, that we feel strongly about, which is the importance of a thorough history, of a thorough, accurate, thoughtful, clinical history. This happened, back when I was a resident. And so it’s a way old story, but there was this gentleman in his fifties, and, you know, we met him under some circumstances for the ENT service. But what was interesting is that he had had severe chest pain that led to a 911 call, and he was admitted for a full mi workup, which is myocardial infarction. Like, truly, you know, yes, he was a previously very healthy, fit guy, but of course, severe chest pain, you know, we take that very seriously. He got a full heart attack workup. It was negative. What had he done earlier that day? You know, like, what were the things preceding the severe chest pain? Okay, one, he worked out, quote unquote, really hard at the gym, end quote. He came home and ate three pineapples. His wife had found a deal at Costco. So for some reason, there was an unusual number of full pineapples around, and that’s shortly after that is when the severe chest pain came on. So, again, like that clinical story, well, that totally changes it. Not to say that that person doesn’t get an ekg in labs and, like, a thoughtful mi m workup, but just it makes more sense in the context of his day. And so, again, these are interesting, fun things to think about. I am definitely a person who super believes in the importance of the clinical history, and we can talk more about this in the future. But I wanted to introduce this idea today for our discussion. And from my standpoint, I see a lot of these multifactorial loringal problems. Often those patients will have some element of cervicalgia or neck pain. They’ll have maybe some muscle tension dysphonia, muscle tension dysphagia elements as well. lifestyle factors and elements on history hugely inform our diagnoses. And so I say all of this, too, as an ENT surgeon. And I typically see patients every 15 minutes, whether they are new or not. And so we’ll certainly contrast that with some elements of Catherine Booker’s practice today.

Katie Booker is a physical therapist with a specialty in pelvic floor dysfunction

Today, as I mentioned, we welcome Katie Booker to the podcast, and very excited to dive in and chat with her. But first, I’d love to introduce her formally. Katie Booker is a physical therapist with a specialty in pelvic floor dysfunction. Katie received her bachelor’s degree with honors in health sciences and administration from James Madison University in 1998. She then received a master’s degree in physical therapy and her doctorate of physical therapy degree in 2004, both from Shenandoah University. Katie is the clinical education coordinator for Inova Physical Therapy Centers and a, ah, certified clinical instructor through the American Physical Therapy association. She prides herself on a holistic approach to all aspects of patient care. And she’s married with two children and three dogs, Bella, Fenwick and Bethany. In her free time, she enjoys reading, exercise, and spending time with her friends and family. Hey, Katie, it’s great to see you, and thank you so much for joining us today.

Katherine Booker: Thank you so much for having me.

Dr. Frances Mei Hardin: Well, and, we have so much, you know, we have so much fun talking. We have a lot in common in terms of our love, certainly for the thorough clinical history. I’d love if we could start by learning about your background and what led you to specializing in pelvic floor dysfunction.

Katherine Booker: I decided to specialize in pelvic floor dysfunction primarily out of necessity for my own personal work life balance. at the time, our referral source for outpatient orthopedic physical therapy, which is your, what most people think of when they think of physical therapy, was changing, and we weren’t going to get as many orthopedic patients in the clinic that we were typically used to. So in order to continue to keep our business thriving, we decided to diversify the services that we offered. And it basically, as clinicians, we just kind of sat down in a staff meeting one day and kind of figured out, based on the area and the growth of the health system that I work for, in anticipated growth of them, where we could go to best serve the needs of our community. And one of those things or areas of patient care was pelvic floor. And it was basically myself and another clinician. And we decided that was the

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Katherine Booker: path that we were going to choose. And we started to take continuing education classes to learn all the ins and outs of the pelvic floor and to help our, patients in our community. Yeah, it came out of, you know, both financial need, but then also what the community needed to at the time.

Dr. Frances Mei Hardin: You know, my understanding is that at the time that you made this move, then it was pretty much at the forefront of pelvic floor physical therapy. Like you were. You guys were early to this party.

Katherine Booker: We definitely were early, in our area. And, you know, I had a very small exposure to pelvic floor physical therapy when I was in, school. That was in the early two thousands, like you mentioned. And there just wasn’t a lot of, availability for these patients with diagnoses, both male and female. So we really needed to address the needs of our community and step up and provide these services, as well as keep our business going.

Dr. Frances Mei Hardin: Exactly. But I do think that even, like, this short story helps illustrate another example of something we talk about a lot on here, which is career agility and kind of like, looking at the gameplay. And you made a very strategic, thoughtful move which benefited patients in your community, but also benefited you from your own practice and business standpoint.

Katherine Booker: Absolutely. I really needed my work to need me more than I needed my work, in the sense that I could provide a skill set for the patients in the community that would be in demand so that I could have a little bit of say in my schedule as far as when I could be available to patients. Cause at that point in my career, I had small children that needed their mom. So I wanted to be able to be both at home as well as in the office with my patients.

Dr. Frances Mei Hardin: I love that. I think that that’s such a smart quote, too. I wanna highlight that. So I needed my job to need me more than I needed them.

Katherine Booker: Right.

Dr. Frances Mei Hardin: That is very insightful. That’s certainly you were before your time. Is there any specific inspiration or, you know, mentor who helped you have kind of, like, that level of acumen as a healthcare worker? Not all healthcare workers think like that, you know?

Katherine Booker: Right. I would say definitely my first, director, where I work was probably instrumental, in kind of encouraging me to have that sort of thought process in the sense that she would always say, healthcare can be very circular, management decisions can be very circular. This will always be here, but your family, you know, your children, and all of your personal needs are going to change. And so that should always be a priority to you. And so I was able to kind of take that information, you know, she didn’t directly say it, but kind of take that thought and put it to work.

Dr. Frances Mei Hardin: I love that. Well, you know, and that’s a skill in and of itself. Like, we get all sorts of incredible advice, but then we have to be able to apply, and so. Right, right, absolutely.

Pelvic muscles play a pivotal role in organ function, whether it’s reproductive

So, you know, for those of us, you know, me included, certainly as an ent, can you define and kind of explain pelvic floor dysfunction, what those symptoms look like, what that presentation is like?

Katherine Booker: Sure. So when we think about the pelvis, typically everyone is just, you know, they think about the bones on the side and the ligaments and how the glute muscles influence the movement of the pelvis. And they don’t really think about those skeletal muscles that live within the pelvis themselves. And what makes this area unique is that we can’t see them, we can only feel them. But they play a pivotal part in organ function, whether it be reproductive health, sexual health, digestive health. When we think about the pelvis, you know, we consider the bones, the ligaments, the muscles, and the glutes, but we don’t consider the impact of the muscles internally because we can’t see them, we can only feel them. But they’re necessary for some very specific aspects of organ function. The sexual, function happens there. Digestive, activities, processes happen there, all the things. And so those muscles are influenced by organ function. And if those muscles aren’t working, well, that’s going to influence organ function, whether it be digestive health or sexual health. So my scope of practice is very broad in the sense that I can treat a male with constipation, and then the next patient on my schedule can be a female who’s postpartum, about three months. So there’s a lot of variability in the patients that I treat as far as their, gender or pelvic diagnoses. But what’s the same is the area that I’m treating in the

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Katherine Booker: sense that it’s the same group of muscles. It’s the same processes that all these muscles have. However, there’s a lot of individual variability and uniqueness to every patient that I see.

Dr. Frances Mei Hardin: That’s awesome. And, yeah, I do think that, like, well, some people don’t like clinic, and they’re never going to like it. I actually really enjoy clinic. I love the time to chat with people and kind of get to the heart of, you know, their symptoms and their stories. But as I kind of introduced earlier in this episode, the clinical history is key.

A lot of pelvic floor dysfunction is related to what the patient’s doing

And one thing that I think is so incredible about your practice that I had learned about you is that you get 45 minutes appointments with your patients, and so you have that opportunity for kind of even more detailed, intricate, thoughtful conversation with them. and my understanding even further is that a lot of pelvic floor dysfunction is related to what the patient’s doing and their behaviors and their habits and so forth. So can you share with us a story when your ability to really get to know a patient over 45 minutes led to a breakthrough in clinical care, and I’m sure that you’re just like, well, every day, but if you could give us some insight into, like, those things that you look for.

Katherine Booker: Right. So when I bring a patient back, first I kind of say, all right, are you familiar with physical therapy? Like, what do you know about this? Because I don’t assume that their referring provider gave them any information. Some of them do, and then some of them don’t. so I try to meet the patient where they are, and if they have had no experience with physical therapy, I need to start there. And then if they’ve had experience with physical therapy, I then say, okay, this is how pelvic floor physical therapy is different. And that’s basically like I was talking about before that. Now we’re going to talk a little bit how these organs are impacting the muscles in your pelvis primarily. And then I really believe, like you, in the importance of a thorough health history, in the sense that if I take my time and I ask the right of open ended questions and I really listen to the patient, they’ll tell me what’s wrong with them and they will tell me how to fix them. So I basically say, all right, here it is, give me the story. And I just let them talk. And I always tell them, you can say whatever you want at any point because I am fortunate in the sense that I have 45 minutes, right? So I tell them they don’t need to decide what’s important, what’s not important. That’s not their job. Their job primarily is to give me all of the information and let me decide what’s pursuable as far as asking more questions. So I will ask them about activities and sports that they did when they were children, because I want to know if there was any previous trauma to the pelvis, because trauma is cumulative, right? So if an area, if a patient fell down the stairs or they were in a very traumatic car accident, nine times out of ten, their body, their musculoskeletal system, has learned to compensate for the areas in their body that was injured as a part of that accident. So over time, motor plans have changed, recruitment patterns have changed. There’s been small little compensations. They’re doing little things. You know, they’re taking a lot of bladder irritants in during the day, they’re not getting enough fiber. So all of these things are going to impact the pelvis and the pelvic floor function.

Dr. Frances Mei Hardin: What sports do you find really predispose someone to like pelvic trauma?

Katherine Booker: Well, I mean, I would say a lot of, I mean, contact sports, obviously, but I also see my fair share of gymnasts.

Dr. Frances Mei Hardin: Oh, oh, sure, yeah.

Katherine Booker: Ah. As well as dancers, only because those, those activities, they live in extension, which alters the length, tension relationship of the muscles in the abdomen and the back. So it lengthens the abdominal muscles, shortens the, erector, spinae muscles. Therefore the pelvic floor is altered as well. My dancers and my gymnast also aren’t great at using their breath for movement. So when we’re talking more about the health history. So I will also ask them, you know, what are your favorite foods? What do you like to eat? What did you have for dinner last night? And I want to know routinely, you know, do they eat the same thing every day? Because then I’m, you know, kind of probing a little bit about their gut microbiome, and I want to know how often are they having a bowel movement? And then I pull out the Bristol stool scale and I say, what does your poop look like? You know, I always say, choose your poo.

Dr. Frances Mei Hardin: Oh,

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Dr. Frances Mei Hardin: my gosh.

Katherine Booker: Yeah. Because I want to know, because, you know, it does tell me a lot about sphincter function. If they’re small little pebbles, then obviously they’re dehydrated, but those muscles are not relaxing enough or lengthening enough. We’re not bulging enough to allow stool to pass easily. I want to know about the flow of their urine. I want to know their bathroom habits. You know, do they take their phone in the bathroom and sit there for hours?

Dr. Frances Mei Hardin: Oh, yeah. Is that bad?

Katherine Booker: That’s bad. That’s very bad, yeah. Creates negative tension, you know, negative pressure on the external anal sphincter. You shouldn’t do that. You shouldn’t do that. You know, do they use a, any type of stool for their feet while they’re on the commode? You know, that’s why the squatty potty is so effective, because essentially it, you know, shortens the muscles in and around the colon and allows them to relax in order for soul to pass a little bit easier.

Dr. Frances Mei Hardin: Yeah, interesting.

Katherine Booker: So I want to know, and then do they strain? People have very interesting bathroom habits. The other thing that I ask about is their sexual history, any history of abuse, or anything they want to share with me in regards to that. I want my patients to know from the minute that they walk in to the minute that they walk out, that anything that they share with me is obviously confidential. But it’s also that they are in a safe place and they get to decide what happens and what they talk about. the pelvis is a very personal area, and there’s a lot of patients who come to me with, a very extensive psychosocial background or history. So I want to be sure that I’m sensitive to that. And I know before I touch them or before I examine any part of their pelvis that they’re okay with that.

Dr. Frances Mei Hardin: Absolutely, yes. That totally makes sense. And that’s incredibly important work. And also I think that the humanity that you bring to it, kind of like the compassion for the individual person, not just saying, hey, we’re here, I’m going to examine you. I mean, I’ve seen people start examining the ear without saying, I’m going to look in your ear now. Very startling to patients. They just feel a speculum go in their ear. You know, that’s like a noxious sensation to all of us. And so, I mean, of course, your patients are lucky to have you because you’re putting that level of, you know, humanity into your work.

Katherine Booker: The. The other interesting thing that I do intentionally with my patients is I wear scrubs to work, and. And I do that because scrubs, you know, providers look relaxed in scrubs. There’s not a high, not as high an incidence of white coat syndrome, because I’m not taking an immediate posture in the clinic to say, I’m in control. I’m the boss here. And I feel as if it really helps to disarm my patients in such a way that they can tell me some of these things that they’re just embarrassed to talk about. Because culturally, we don’t talk about our, bowel and bladder habits as often as what we should. And so folks don’t know what’s normal, what’s not normal. And I tell my patients a lot, you know, things are very common, but they’re not necessarily normal.

Dr. Frances Mei Hardin: Oh, I love that. Yeah, that’s very true.

The link between pelvic floor dysfunction and TMJ is interesting

One thing that I wanted to touch upon today is just the fact that we probably have a greater overlap, you know, in patient populations than I had initially appreciated, because, you know, and you could probably see from my face, like, the more you talk about poop, the more I’m like, this is exactly why I became an ent. Like, I don’t. I don’t ever want. You know, it’s funny, but the. The comorbidity of pelvic floor dysfunction and TMJ, I find so interesting.

Katherine Booker: Yes.

Dr. Frances Mei Hardin: And so I’d love to hear, like, anecdotally how much you see that in your practice. What do you think I. Is the link between the two? Is this, like, super tentorily mediated? Like, I’m very interested. I was kind of looking at the literature for that, although a lot of it, wasn’t in, like, mainstream medical journals.

Katherine Booker: Right, right. So I screen all of my patients who have a medical diagnosis of constipation for any type of, TMJ dysfunction. And anecdotally, the vast majority do, or they have a history of bruxism and they wear a night guard. Why is that? I think it has to do. Like, we can get clinical, and we can say that, you know, neural tube development, but typically, you know, the tube, if the tube is tight, going in, then the tube coming out, essentially is also tight. And these patients historically

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Katherine Booker: can have a history of, cervical spine dysfunction. But primarily, what I’ve seen clinically in my patients with a history of constipation is that they’re using their diaphragm as a postural muscle. So their diaphragm has lost that ability to be the pump, be the secondary pump, not only to move for the lungs to expand, but also to help the nervous system regulation for the stool to move through the colon. In physical therapy, we view, you know, constipation, anything with, defecation, as a movement concern. So we’re looking at how that patient is accomplishing that bowel movement on that particular day, at that particular time. And those patients that report constipation or history of bruxism, or they wear night guards. You know, I look at their compliance with wearing the night guard. I look at their fiber intake. What’s the balance between soluble and insoluble fiber? And then the other, clinical anecdote is these patients are typically very, intense exercise participants. So they’re doing the high intensity interval training, or they’re running two and three times a day. So there’s a lot of stress being put on their nervous system, meaning that they are driving primarily their sympathetics. And so there’s not a lot of rest and digest happening. So we talk about mindfulness, we talk about stretching, we talk about breathing. The only clinical supported breathing approach is circular breathing. And this came out of, And I apologize. I don’t know the author’s name off the top of my head.

Dr. Frances Mei Hardin: It’s okay. We can link it later in the show. No problem.

Katherine Booker: But it talked about the most beneficial breathing as far as creating that heart rate reserve, which is super important for everybody to have. Our heart rate variability, I should say, is circular breathing performed six times a day, two minutes, where they breathe in for 4 seconds, and then they exhale for 6 seconds. So that’s helping to stimulate the vagus nerve, stimulate the pumping motion of the diaphragm, as well as support nervous system health so that the parasympathetics can get, become a little bit more resilient. And sure enough, we can have bowel movements without stress and strain.

Dr. Frances Mei Hardin: That’s amazing. I, want. You probably see me here now I’m, like, thinking really hard. I’m sitting here trying to breathe. I’m definitely a person who forgets to breathe and, like, maybe lives in the perma sympathetic state. I’m trying to fix that. So that’s very helpful. But I. I can’t believe, like, that two minute circular breathing practice. You said six times a day.

Katherine Booker: Six times a day. Which, I mean, come on. Right? But we have two minutes. You know, that’s. Sometimes that’s a, huge piece of time for a patient to take on and digest. But I’m like, you’ve got two minutes. I don’t care so much about the six times. If I can get you doing it, you know, three times a day, I’ll take it. Our bodies don’t know when we’re doing good things for it. It just knows that we’re doing something. Okay. It’s just our brain kind of gets in the way, so we just need to create environments and create habits that will support, you know, making positive decisions and positive things for our health.

Dr. Frances Mei Hardin: I love that. But you’re so right. Like, the brain doesn’t know that that’s good for it, because, like, you say that, and I’m like, what? Homework? Six times a day homework? Like, ah, you know, absolutely not. Then my to do list is already, you know, quite hefty. But I do want to. I really appreciate, you know, your explanation of that, because that makes sense. And it helps me even, because I see TMJ, certainly multiple times a day, most clinic days, more than. More than once a day. And, you know, bruxism, for everyone, you know, that’s where we grind at night. And then I see, of course, a ton of clenching during the day. I was actually having a conversation with my audiologist just recently because we saw this patient where it’s so funny, you know, they’ll tell the nurse, nope, never had jaw trauma. Never had TMJ, you know, and I don’t grab my teeth. And they told the audiologist as she was doing a full workup, audio and tympanometry, you know, for bad ear pain. you know. Yeah, never hit my jaw. Like, no jaw trauma, no bruxism, no clenching during the day, nothing like that. But it’s so funny, because one thing that has really made a difference in my practice is that in addition to all those questions, I start giving super concrete examples. I will ask people, have you ever flipped over handlebars when you were a kid? Because what I’m getting at is, I want to know, did they ever hit the underside of their chin on something?

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Dr. Frances Mei Hardin: Because, and, you know, not uncommonly, people will be like, you know what? Yes, I have flipped over a scooter, or I flipped over a handlebar, or, hey, and then they’ll point to a, you know, a horizontal scar under their chin, not one that just anyone would see, but, you know, they’ll show you and they’ll say, that’s true. Like, when I was a kid, I did hit this really badly. And now they’re presenting with, you know, signs of TMJ, joint derangement. And one of the reasons is because, of course, that mechanism of injury, it kind of drives up both tmjs, you know, up into the joint. But that’s such one that we don’t even think about because that’s not trauma directly to the joint itself. Although I’ve had people say, yeah, I opened up, or like, you know, a door at home opened up right into my TMJ, and it’s been hurting ever since. And I’m like, yeah, that’s, that’s pretty much a slam dunk. Like, that sounds like that’s what it is.

Constipation can decrease bladder capacity, which can lead to urinary dysfunction

You hit it right on the, on the joint.

Katherine Booker: Right. So in physical therapy, if I were to hear something about that, you know, now I’m. Now I’m considering. Okay, well, how have they modified, obviously, there some sort of trauma to that area. So now what does their breathing look like? What does their posture look like? How do they deviate when they open their jaw? What are their pterygoids doing? So that’s an example of something traumatic, how the body has learned to go around that trauma and develop motor plan compensation that can be pretty significant long, term. That’s probably my favorite part of, the kind of work that I do. And I tell my patients, I’m always trying to figure out who’s driving the bus, and I just start digging and layer after layer, sometimes I will say that they’re like onions and they can make me cry, but I’m just peeling back all of their various compensations and trying to figure out the primary driver for whatever dysfunction they happen to be showing. And a lot of times, constipation is a big driver for any type of urinary, issue. Just because of real estate in the pelvis, there’s only so much space. So if the bowel is distended with stool, it’s going to push on the bladder. So you’re going to see a lot of increased urinary frequency. And if you layer on some bladder irritants, and not a lot of water intake. These patients are going to the bathroom a lot, and therefore they’re decreasing their bladder capacity. And their pelvic floor muscles are getting weak because they don’t get the opportunity to do their job, which is to keep those sphincters closed.

Dr. Frances Mei Hardin: Wow, this is more than I ever thought I would learn, but I really like it. Makes perfect sense and it’s super useful. Like, this is honestly, I guess I should have been putting probably more thought into this because it definitely, I’m sure more patients than I know do deal with this, even when they come in to me for the TMJ side of things. Like, yes, they’re two ends of kind of the same tube, so it does make perfect sense.

The incidence of pelvic floor dysfunction is very high among women who have children

One thing that I wanted to move on towards, and it’s certainly tangentially related, is that I love the quote, if you don’t make time for your wellness, you will be forced to make time for your illness. And so I’d love to hear your thoughts and interpretation of this old adage, like, is it true? Is it not?

Katherine Booker: Oh, it’s a thousand percent true. I actually have a poster, in my office with that same sentiment that it says, if you don’t pick a day to relax, your body will pick it for you. So, same sort of thing. You know, our body’s always giving us information about what we’re doing, how we’re, how we’re doing things. And if we’re not paying attention, then we can develop some pretty interesting habits that can long term not serve us in the best way. And that’s how patients necessarily or can end up in my office. you know, the incidence of pelvic floor dysfunction, especially, you know, if you think about women, you know, prolapse especially, you know, that’s, 40% to 60% among, women who have children. So that’s a lot. That’s a lot. And that’s just considering one pregnancy, and that does not account for, how the baby is delivered. It’s just the actual stress and strain on the pelvic floor that can lead to the, pelvic organ prolapse.

Dr. Frances Mei Hardin: It happens to 40% to 60% of women.

Katherine Booker: Yes. Right.

Dr. Frances Mei Hardin: Oh, my gosh.

Katherine Booker: Yeah.

Dr. Frances Mei Hardin: At first I hoped you just meant 40% to 60% of people who experience prolapse have kids, but no, no money. Oh, my gosh.

Katherine Booker: Correct. Yeah. So, I mean, culturally, you know, I would say that we’re definitely changing a lot of habits, but previously we just didn’t talk about that, which

00:40:00

Katherine Booker: is why, you know, there’s all these products in our stores to assist, with any type of issues related to pelvic floor dysfunction. So, with prolapse, you can get the cystocele or rectocele, which basically are named for which part of the vagina, the vaginal wall, is now visible at the introitus. When I see that clinically, I always tell my patients, this looks like this is happening, but I very caution, or I’m very cautious that I don’t practice medicine without a license and say, oh, you have a cystocele? because that’s not my call to make. That’s for the physician to say, but I treat them as such. And so we talk about supporting the muscles in and around the pelvic floor. But, yes, the. The incident rates around prolapse are very high.

Psych coordinator for clinical education helps place physical therapy students with clinical instructors

Dr. Frances Mei Hardin: I’d love to shift to discussion of your very important work as the psych coordinator for clinical education. So can you tell us about your role, the responsibilities, and all the different centers that you oversee?

Katherine Booker: Yes. I am in charge of soon to be 18 centers that I take physical therapy students who have completed most, if not all, of their didactic information and now are essentially ready to be in the clinic with their clinical instructor. We typically make those decisions march, April, and then students start their placements the following year, meaning I. This past March and April, I was placing students for 2025. So it’s a bit daunting that I’m working that far ahead, but schools need enough time to know what potentially would be available, and it’s very dynamic. It’s very much like my daily patient care schedule that it changes a lot. Placing a student with a clinical instructor is a lot like dating, so I kind of feel like a matchmaker because I want to make sure that the CI gets a good student as well as the student gets a good CI, and ultimately, you know, they are able to learn from each other. I really enjoy that part of my job, just seeing the AHA moments happen with the students as well as the CI, you know, getting a little bit more of the warm fuzzies as far as, you know, professional growth, and seeing how what their knowledge is impacting the future generations of physical therapists.

Dr. Frances Mei Hardin: That’s incredible. Do you feel like you have enough information from both sides to matchmake?

Katherine Booker: Sometimes. And sometimes if I don’t feel as if I do, I’ll reach out to the school or the student and say, tell me a little bit about your learning style. A lot of the PT schools will provide that information for me, but if it’s not sufficient or I just want to know a little bit more about the student, I will just reach out to them directly.

Dr. Frances Mei Hardin: I love that. That’s incredible. I’ve never, I’m not sure that any med school matches people that way. You know, we just kind of like, no one, no one is like, what’s your learning style? And then usually if you say your learning style, you just get, like, yelled at or something a little bit. Kidding. But I’m not 100% kidding.

Katherine Booker: Right, right. Well, you know, we don’t have that in physical therapy. I mean, we, we are always, you know, we’re kind of seen in medicine as, you know, we’re the nice guys. You know, we’re the. Where the, movement doesn’t have any negative side effects, folks. So we try to ensure that our students are placed in settings with instructors that are only going to help them develop their own clinical thinking and reasoning.

What differences do you see in working with this next generation of physical therapists compared to previous generations

Dr. Frances Mei Hardin: What differences do you see in working with this next generation of physical therapists compared to when you came up?

Katherine Booker: Right. So I really enjoy working with the physical therapy students that are kind of, you know, at the tail end of their education because they’re really going big picture. When I was in school, it was more about like, okay, I’ll get a job. Great, okay, what do I have to do? You show me the hoops, I’ll jump through it. I didn’t question anything. I didn’t have ask for anything. I just kind of took whatever they were offering, and I would say, now with therapists, they want to know the why behind a lot of the decisions that we’re making. And I enjoy that challenge. I don’t see it as, disruptive or disrespectful, and I don’t respond to it with, well, that’s how it’s always been.

00:45:00

Katherine Booker: So I try to give thoughtful responses to those types of questions, and then I ask them, do you think that there’s a better way? a lot of times, you know, especially in staff meetings, if we have a student in clinic that I, you know, where I’m working and somebody says, well, students really like this, I will say, well, why don’t we ask the student that we actually have in the clinic if they agree with that statement? So I think, including them and asking for their feedback, they’re willing to provide it if we give them the opportunity and the space to really, speak their mind.

We’re talking about health and well being at work

It’s interesting because, we’re talking about health and well being at work. And an interesting contrast that’s come up just with us, with our staff at work is, I perceive me, I’m Gen xer. Health and well being is I don’t have to fold laundry anymore. I have pretty consistent opportunity to park my car in the same place every day when I come to work. So to me, that’s health and well being. Whereas some of my younger cohort therapists, ah. Will perceive health and well being as more productivity requirements. And do they have time for, you know, seeking out, just breaks, you know, just a lapse in their, their schedule where they can kind of clear their head for a couple minutes. And so it’s very different how all of the generations and all of the clinicians perceive the workplace and the challenges that each workplace provides. The generations, I should say.

Dr. Frances Mei Hardin: Yeah. Well, but, first of all, first of all, thank you so much for not being a person who says as a response to a question, because that’s how we’ve always done it. I could just like you’re, you know, you’re vip of this whole week, because I think that that’s part of the start, like, in healthcare, especially for healthcare workers. Not everyone is so open minded, but I do think that, you know, it’s, it’s wonderful to chat with you and connect with someone, like, very brilliant. You have to be confident to be open to these conversations. I actually interpret it as a lack of confidence. When people kind of, you know, issue a question or they say, because that’s how we’ve always done it, it’s like they actually may not know why we do it this way. Like, you honestly may have caught them with their pants down. Like, they don’t know. But instead of saying, hey, I don’t know, you know, there’s a lot of, I see this all the time, like, the willingness and the ability and the action of saying, huh? I don’t know. I’m not sure. Oh, let’s go ask someone else, or we’ll go look it up, or we’ll go talk about it. That is a sign of intelligence and competence, right?

Katherine Booker: Yeah. I don’t know is an answer, right? I mean, it is. And so I think allowing yourself to be vulnerable in that moment is okay. And I think it’s definitely something that’s, you know, respectful if you’re working with, you know, colleagues that are younger and say, I I’m not sure, but let’s explore that, or do you have any ideas on how we can make this process better?

Dr. Frances Mei Hardin: Yes. And I say that all the time. I literally think I said that in clinic this morning. Just in terms of, you know, I mean, I’m in solo practice at a rural community hospital, and we also are the only clinic that takes all the insurances for just, like, hundreds of miles. And so we get genuine conundrums whether. And they’re not just clinical conundrums. They’re, like, societal. You know, there’s, like, social, determinants of health at play. There’s, like, support systems that maybe are at play as well. And so we will even talk as a group, and I will say to the whole team, I’m like, what do you guys think? Like, okay, well, let’s think this through. I guess we have these two options. You know, what do we think of the pros and cons of each? And so. So just getting feedback from other people, I think, only strengthens the healthcare team, like, approaching this as a team. And I think we all have very vested interests in our patients doing well from our Ent clinic. Like, we all care about that. Every single woman who works in the office.

Katherine Booker: Right, right. And I would also say that this. The current younger generations, they’re more collaborative, which I really appreciate. It’s not. Whereas before it was, you know, when I was first started with my career, if I had a question, I had to dig deep to find the answer on my own. And now I feel like I have this team that I can turn to and say, what do you guys think?

Dr. Frances Mei Hardin: Yeah. Yeah. So some things are moving in the right direction, and hopefully they continue to do so, but they will as long as the people in leadership positions and the people who are role models for the next generation display these qualities. So, you know, certainly your students are lucky to have you as well.

00:50:00

Dr. Frances Mei Hardin: What advice would you have for the next generation of physical therapists?

Katherine Booker: To always be curious, definitely. To not, become complacent with patient care. You know, still be excited about it. I think if. If at any point you don’t have that kind of fire in your belly where, you know, going to clinic is exciting, then you really should step back, because that’s not fair to the patients that’s sitting in front of you. You want to be curious as to their why. What’s their driver? why are they showing up in your office at this point? The physicians have done an excellent job of ruling in and ruling out medical things, and so they’re coming to you with, likely a diagnosis that’s causing them some psychosocial stress. so taking the time to really dive deep in that thorough health history and figure out why they’re presenting the way they are. So curiosity is definitely the key to, I think, longevity, in physical therapy, as well as possibly all aspects of healthcare.

Dr. Frances Mei Hardin: Definitely that would be a big part in medicine. And arguably, though, even from a brain health and cognition standpoint, like, curiosity is the answer to longevity for us, for you. So, you know, all around. That’s, that’s wonderful.

It’s been such a joy learning from you

Thank you again for joining me today, Katie. It’s been such a joy to learn from you, even about poop, even that. The fact that you’ve made even that very understandable, very enjoyable to learn about is like a testament to your, to your skills. Follow me on Instagram at Frances Mei, MD and rethinkingresidency. Visit my website, rethinkingresidency.com, to learn more about resident physician stories and ways that residents can most effectively navigate the game of residency. I cannot wait to connect with you on the next episode of Promising Young Surgeon.

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