There was a discussion recently in a Facebook group regarding frustrations with difficult patient encounters and advice on how to best manage these cases. Here below, I have provided a brief list of advice imparted onto me by mentors of mine. Hopefully this helps…..
One of the best pieces of advice a professor of mine gave me was “that you cannot control how people act, you can only control how you react”. This simple quote or credo is so incredibly true and is a great approach to life in general. People can be irrational and their actions frustrating, both of which may become magnified surrounding episodes of poor health.
Another thing to consider, which is a message I’ve adapted from an icon of mine Cael Sanderson, is that every challenge that you face is an opportunity for growth and that we should look forward to challenges; they make us better. Difficult patient encounters are opportunities to learn how to manage difficult patient encounters and it will get easier. It’s also always important to consider that the people we serve could choose elsewhere. They don’t have to be in our clinics. Even in public or federal systems, the patient can still choose to not show up. Take it as a privilege that YOU get to SERVE them and even though they may state that they don’t want to be there, they still decided to show up. Also realize, (and I’ve learned this working with many disadvantaged populations) for many people, even getting to the clinic may be more difficult than you may ever realize.
Regarding verbose patients; there are many people who come to our clinics who have never had the opportunity to speak to a healthcare provider about their problems. Some may not have the opportunity to share their frustrations with anyone who cares or has concern for them. This issue of social isolation and loneliness is a real and growing problem in our modern society. Therefore, consider it a privilege that they are comfortable enough to be verbose with you. Just taking time to listen to them can go a long way. In terms of managing verbosity, because there are time constraints to clinical practice, what I have found to be useful is to try to steer their conversation around the goals for the session or intercede with questions that may help redirect it. Always try to acknowledge what the patient has said before talking, this helps convey that you did listen to them (you really should be), which is important for building trust and rapport. This process can be difficult but it gets easier over time as well.
Regarding patients who are difficult to convince or establish buy-in for your plan of care, especially those who may believe in more liberal interpretations of physiology, be persistent and steadfast but always be respectful and considerate. Remember that few people possess the specific knowledge of human physiology to determine a falsehood from truth as it pertains to disease and 88% of US population is insufficiently healthcare literate. Given these factors, and others it is incredibly difficult to change someone’s views once they have internalized information; ie “You can’t sell meat to vegans and you can’t convince a carnivore to eat vegetables”. If their views interfere with your best judgment as a provider, consider referring them elsewhere; it’s probably best for both. We as a profession and field (healthcare) need to do a better job addressing this process of translating knowledge to our communities both at the clinic level and institutional level. But it all starts with a conversation and re-framing expectations with each individual. At the fundamental level, a clinician is an educator and motivator.
These are just some recommendations and tips. I don’t practice as much now but can recall how difficult it can be in the clinic and realize that things are rarely ideal and we all have our limits. However, if you consider some of these basic principles and perspectives, it helps make difficult situations a bit less stressful when they do occur.
(Image courtesy of Gomerblog.com)
A little advice regarding the nature of discussions in this forum and elsewhere:
If one posts anything publicly, or really anywhere to a broad audience, one must realize and understand that individuals will offer both support and criticism. It’s part of the process and not everyone will view things the same way, for many reasons i.e. Knowledge base, biases, experiences etc. Few things in life are dichotomous in nature, where there is an absolute truth and false. Public discussion in any setting is NOT for the meek of heart. If one doesn’t possess the gumption to handle criticisms or contrarian views, they should perhaps reconsider participation in public discussion. Furthermore, if what one posts is so easily criticized, perhaps one should consider heeding the criticisms offered or at least reconsider the merits of what one one has posted. I would also wager (no empirical data to support this, this is based on the multitude of professional discussions and arguments I’ve participated in) that most people who decide to criticize (especially peers) do so out of genuine concern and a desire to improve.
Now I do agree that there should be some ground rules to discussion/argumentation for the sake of decency and purposeful argument, ex. criticisms should be purposeful, valid and follow a sound logical framework. One should also consider how incredibly difficult it is to change someone’s views on any topic, much less when those opposing are steadfast in believing their views to be true and when argument is done via textual mediums of communication. Being outright rude makes that task even more challenging. Why work against yourself? However, not everyone agrees with the same ground rules as I or anyone else; which one must also understand. However, one doesn’t have to respond to criticisms offered either, there’s always a choice.
You could heed this advice or not and continue to become overly offended and attempt to silence others who offer views that differ or continue to be unprofessional in discussions with peers. Ultimately it makes no difference to me, I will still continue to go about how I have regarding discussions. Just some advice. We accomplish little with categorical and unconditional agreement, iron sharpens iron. However, nor do we with shouting matches instead of purposeful, respectful yet incisive discussion.
Also, one should consider entering discussion or argument under the condition that what they argue may be wrong. One should be prepared to argue their point vigorously but be willing to concede when what they argue is shown to not likely be true. If one is not willing to make that concession, there is little point to engage in argument. This is actually a cardinal rule of formal argumentation. This cardinal rule is also something to consider, before posting publicly or one will have a hard time due to the nature of public discussion described above. One should also consider realizing their limits to the value of their opinion and degree of expertise, ie, acknowledge what you know, what you don’t know and that there are people who might be more versed on a given topic. Quick tip, if I engage with someone, I haven’t encountered previously, I usually do a quick search on who they are so I know who I’m discussing with and if I might be out of my league. That’s not to say that we should view the thoughts and opinions of experts dogmatically but it should be in the back of one’s mind that perhaps their opposition might know a bit more on a topic than oneself.
Following the most recent media craze around cupping and other alternative medicine in MSK rehab, many in our profession have provided commentary on this issue. I feel that this most recent event highlights a bigger issue within our profession, which is the role of the clinician. My opinion on this matter was requested by a colleague of mine on a thread, which realizing how long it became, I felt might be good for blog post. Please, enjoy and let me know what you think!
Though I am more in the lab and lecture hall now as an academic, I still see a few patients and serve as a clinical educator to both students and practicing clinicians. This is my general view of the role of the clinician in communication with patients and the community:
A clinician should be confident in their understanding of the human body, based on the current accepted body of knowledge, while humbly accepting their personal limits of understanding and the current gaps in knowledge. They should also avoid filling those gaps with ideas that escape the realm of scientific plausibility, especially when interacting with patients and their community. The reasoning behind a given treatment is almost as important as the physical act. Our thoughts and words matter, a lot. This is a particularly important concept to bear in mind. Remember when interacting with a patient or the community it is from a position of authority (a clinician is viewed as an expert), in that power dynamic people tend to believe what is told to them. Therefore it is imperative that we strive to ensure that the information which is communicated to patients and the community is as truthful as possible. More on the consequences of failing to do so by my colleague Kenny Venere PT, DPT (FYI he’s a bit blunt).
Clinicians should remain committed to becoming excellent in their field and learning more throughout their career and most importantly doing right by their patients. Sometimes that means being a discerning yet respectful voice of reason to the patient and in community to the nonsense that is perpetually disseminated by others, for whatever reason. A clinician at the core is a motivator and an educator. As an educator sometimes what’s right isn’t popular and it’s not easy to tell or convince someone that they’re wrong. However if someone is wrong it’s important that they are told so but it should be done in a respectful manner. Changing someone’s opinion on anything is incredibly difficult and it doesn’t become any easier by being boorish and discourteous. Always remember to be tactful and be mindful that some people just won’t change, despite how well informed a counter argument might be or the degree of cognitive dissonance present. Clinicians should also learn to effectively communicate, empathize and relate with the different types of people entering into a clinic. Communication and use of language is probably a clinician’s most important tool after what’s between the ears.
Lastly, the majority of patients arriving at a clinic already are confident enough in a providers abilities, as they likely wouldn’t be there otherwise. Even if a given clinic is the only one covered by a patient’s insurance, most have the option of not showing up (trust me I’ve practiced in systems like this and people still don’t show up). Therefore they don’t need to be sold on some esoteric and novel for the sake of being novel treatment, they just want to get better. They are seeking the help and guidance of a clinician to do so and they also want to be listened to by someone who cares. Listening to a patient is not synonymous with doing whatever they want so that they feel better. Listening is using the information they’ve provided to develop the best choices for them to make, we’re providing them guidance and options that they have to choose. It’s a give and take but the role of the clinician is the adviser, that’s why a profession requires so much schooling, training and licensure. Also factor in that most MSK injuries are self limiting, we don’t really need to make rehab too complex or creative. It just needs to be intense enough so the patient progresses to meet their goals in the most effective and efficient manner and creative enough to keep them interested.
In short, keep it simple and use the body of knowledge to inform and guide decision making (not replace it), stay current, be an adviser for patients and community, be careful with use of language and have the courage to offer a discerning opinion and humility to accept one. This is not always easy to do in the clinic while working with individuals with health related problems (who we all want to help get better) who may have been exposed to all sorts of information/misinformation and may take some convincing. However, if a patient doesn’t want to listen to a clinician’s advice they can always go somewhere else. We aren’t short on people needing help and if a patient doesn’t buy in they probably aren’t going to have too much success with that clinician anyway. This is basic marketing/argumentation/social theory, as an example people who are vegans aren’t interested in people trying to sell them meat but there are plenty of meat eaters and they are sure to find those selling meat.
Image: Courtesy of Deborah Dunham 2012; cavementimes.com
On May 30th 2012 the New York times published an article (http://well.blogs.nytimes.com/2012/05/30/can-exercise-be-bad-for-you/) on a study by Bouchard et al (http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0037887) which had discovered significant cardiometabolic adverse reactions in patients following exercise interventions. This report combined the findings of 6 studies and had a total of 1,687 subjects of various levels of health, risk factors, gender and age. These findings were quite profound in that currently exercise particularly aerobic exercise is recommended for patients to prevent or reduce the risk of cardiovascular pathologies. There have been numerous studies that support these claims; all one would have to do is search “exercise and cardiac benefits” to PubMed or even google and a plethora of articles in respectable journals would appear. It must be noted that the overwhelming majority of the interventions evaluated were endurance exercise, only two of the studies evaluated had subjects perform resistance exercise and of those two only one of the studies’ data was used in this report.
The authors of this study are all well known and reputable and after reading the article myself I feel that their findings are solid. They effectively controlled for error in measurement by only classifying AR to be greater than 2 standard deviations from the average to even be considered ‘significant”. Their statistical analyses also controlled for bias due to duration, gender and other variables. Their population pool was enormous and quite variable and the dosage of exercise was considerably mixed which made these findings very generalizable.
With all this being said I would agree with the authors in that stating though these findings do suggest that their may be a “statistically significant” percentage of people who experienced a deleterious effect from exercise, about 10% on average, one must must also realize that close to 90% of people did have positive benefit. When you take a step back and re-review these findings you realize that these findings are not that surprising. Any intervention there is always a chance for negative effects. Look at all of the drug therapies that are currently implemented, almost all could cause an adverse effect in a given patient. We are all very similar but we are all different at the cellular level and molecular level. If we were to abandon every intervention because 10% of the population have a negative side-effect we wouldn’t have that many left. The beauty of the healthcare system is that we have such variability in the way we can intervene with patients and treat pathologies. When the standard doesn’t work you try something else. The same should be said for exercise as well.
As a future physical therapist I feel that this issue is something that we can get involved in. By that I mean what the authors suggested in their discussion which is that there is a 20-30% genetic link for some of these ARs. This finding suggests the need for blood work and pre-screening of patient before and exercise plan is ever administered especially to “at risk” patients. The most effective and efficient way to pre-screen someone for exercise is to administer a stress test which physical therapists are now doing more often with the progression of cardiac rehab. We have a chance to really get involve in this and I hope more research is done in the future in evaluating the ability of a stress test’s and concurrent blood work data at predicting ARs for patients. Too often exercise is prescribed capriciously with out considering that you may hurt your patient if you aren’t careful and treat the intervention as a medicine.
I would also like future research to look at the combination of resistance exercise and aerobic on metabolic risk factors. This study only had one group that did both and they had ARs but less in total, they also had one of the smaller sample sizes and were not American.
That’s enough from me take a look at the article and leave your comments below. Time to play cricket followed by watching the UFC fights.
Good evening all! This is my first official blog post ever. I was always skeptical of creating a blog because I thought that they create a mentality of isolationism and narcissism. However, today I had rather illuminating lecture from a therapist who clearly demonstrated the benefits of having a blog and proved my presumptions to be false. Those who know me well realize that I can talk ad nauseam on things that I find interesting. What better way to express my opinions on subjects I am passionate about than a blog. So in short greetings blogsphere I am happy to join you.
The main premise for my blog will be to review articles and topics I have found in the most recent scientific journals and provide you with my opinion. That being said I also will cover topical issues such as injuries and policy affecting healthcare specifically focused around the physical therapy profession.
Thanks for reading!