#VOTPt

David Reed

To the Choir

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Dear Choir,

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I realize that I am preaching directly to you with this note since those about whom I’ll write couldn’t care less.  From you, dear choir, what I will ask is your righteous indignation and to give no quarter to these individuals.  They will either rise or fall on their own merit into a bed of their own making somewhere outside of the privilege and responsibility of caring for patients in need.  The Dude can no longer abide.

Going into a new facility, speaking with clinicians, and reading their notes has me crawling out of my skin.  Observing a clinician day after day providing the same chair exercises and copying/pasting notes is at best lazy and at worst sniffing the foul odor of waste and abuse.  Why does Medicare have all those rules again?

Let me illustrate the issue a little more clearly.  Most folks are aware of the Technology Adoption Curve (fig. 1).  The Innovators are positioned to the front-end extreme followed by Early Adopters, Early Majority, Late Majority, and Laggards.  To note, the Laggards tend to “make decisions based on their own past experience and are often unable to take risks on new ideas.  I propose that the very same curve which has helped to identify the technology-customer and explain how new tech has been so effectively integrated into our society is also applicable in similar proportions as in service industries.  This absolutely includes healthcare.  However, the implications of not purchasing the newest edition of the iPhone are vastly different than the potential dangers of practicing physical therapy, medicine, dentistry, etc… the same way and with the same “experience” we collectively had 30, 20, or even 10 years ago.  I propose that being a Laggard and purporting to be a professional clinician are simply incompatible and unacceptable.

Unfortunately, much of our market – the general public, believe “a doctor is a doctor,” and clinical skill is a given.  Today, the voice of the patient must be heard.  You, dear choir, must represent their voice.  It must be heard clearly in our offices among co-workers, in social circles, and with friends/family.   While there may be some indication that this long-held belief may be changing, re-educating to include all actual and potential consumers of healthcare is

On Second Thought – A Follow Up Conversation with Gabriela Nunez

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Listening to the Gabriela Nunez Episode of The Voice of the Patient Podcast challenged me in a way I hadn’t considered personally in my clinical practice.  While it may be much more common for many types of physicians, especially those working with patients whose conditions may be life threatening, the second opinion is not nearly as common for physical therapists and primary care physicians.  In fact, a quick google search might make one think that cancer was the only reason someone may get a second opinion.  However, one of the links in that search, an article written by NerdWallet and published by FoxNews.com, advises consumers to get a second opinion “When you don’t feel like you are being heard.”  Someone’s been listening to the voice of the patient!

Gabriela’s story was more interesting to me since her story involves more than one discipline of provider and different patient behaviors with each.  She described going to a surgeon where she expressed her concern and received a “pat on the head.”  In that case, she sought a second opinion and was completely vindicated when her concern was investigated and a failed/re-torn ACL graft was diagnosed.  However, Gabriela describes the actual treatment received as “standard protocol – heel taps, SLRs, etc…” She went on to cite discomfort in asking her PT specific questions regarding your treatment and their failure to ask her about her specific therapy concerns.  Identifying with Gabriela, I’ve actually done the same when ultrasound, TENS, and moist heat here significant components of my “rehabilitation” after my car accident a couple of months ago.

In a follow up interview to the podcast, I asked Gabriela about her decisions to seek (or not) a second opinion of her providers.  Here’s some of our follow up discussion:

Me: Can you talk about the difference in your motivation as a patient to seek a 2nd, 3rd, 4th opinions from a surgeon but to stick with a PT who also doesn’t seem to be meeting expectations?

Gabriela: I almost felt like going to someone else would be disloyal or mean since I had developed somewhat of a rapport with my therapist in the early stages of my rehab. I feel no relationship or obligation toward doctors in general, since I have never felt as though they would care one way or another. I felt that my therapist was kind when we did have one on one time. Unfortunately, that time was minimal, and I didn’t want to be an annoying patient, always asking her questions.  I decided that I would supplement my therapy with things I learned in class or tips from my professors. However, few patients have the resources I did, and therefore may have had a worse outcome. Overall, I think many patients feel a bond with their therapist, and want to make them proud by getting better. So I think its harder to be objective about a therapists performance if you feel a connection with them.

 

Me:  You stated, “My healing process would have benefited a lot had she started that conversation [regarding Gabriela’s expectations of therapy].”  Can you tell me more about how you feel your healing process would have benefited?

Gabriela:  I acted tough at the clinic, and I’m sure my therapist thought, as a PT student, I had a clear perspective and positive attitude regarding my rehab. I am ashamed to say that was not the case. In hindsight, I had a lot of yellow flags regarding my rehab: financial stress, stress with school and work, exhausted from living alone on crutches for two months. Additionally, being in PT school during this kept my knee in the forefront of my mind. I often ruminated on how slow recovery seemed to be going, my impairments, etc. After a long day of PT school I just wanted to forget about my own rehab. I was compliant in my HEP, but I did so begrudgingly!  So, I was an emotional baby about my surgery, and I would have benefitted from the ability to discuss my fears regarding my long-term knee function. My surgeon had told me that I would definitely need a knee replacement in a few decades, and I was worried if returning to sport/impact activities would cause me to need a knee replacement sooner.  My therapist’s response to this was to accept that maybe soccer wasn’t for me anymore, and I could find another great hobby to love. This actually made me less motivated to return to my previous level of activity. I set myself easy long-term goals of returning to low impact cardio, weights, and swimming, and gave up the goal of ever playing contact sports again.

Me: How can we encourage patients to hold us, as physical therapists (and any clinician), to the same standards of clinical performance?

Gabriela: [Patients should be encouraged to] be clear with their therapist about their true goals for therapy. The patient should know that they are entitled to knowledge regarding their treatment and health. Clinicians should encourage patients to ask questions! Patients need not be afraid to speak up if you feel they are not meeting their goals for therapy. There may be a physiological explanation that you, as the clinician can explain. In short, patients need to be empowered to keep all of their healthcare practitioners accountable. To be confident in the progress of their treatment, they just need to ask!

Some final thoughts that I’m still wrestling with:

  • Could we be inhibiting patients’ desire to get a second opinion by listening to the voice of the patient working to develop a good relationship?
  • What is the best way to teach the patient that it’s okay to question their therapist with expectation of understanding their treatment?
  • Can the “therapeutic alliance” occasionally impede progress in the clinic? That is, in developing a rapport with the patient, can we actually encourage such a feeling of loyalty that questioning the clinician would feel somehow wrong?

 

Let’s continue the conversation in the comments below.

Voice of the Profession or Voice of the Patient

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It is truly an awesome spectacle to see the dedicated and vocal professionals covering all bases of social media today.  Even better is the traction that patient-centered care has garnered. The idea that more than 3 people (my wife, Zach Stearns, and Dustin Jones) downloaded and even listened to the first few episodes of the VOTPt podcast is pretty fantastic.  If you haven’t listened yet, check out this episode with Emil Berengut and be blown away.  With this growing chorus of professional advocacy, it’s critical the patient remain that singular voice around which we all center our growth, practice, and advocacy efforts.

As I write, I’m on a plane headed to Washington DC for a weekend of FSBPT meetings (okay, maybe a little less exhilaration than CSM generates) reflecting on the important differences between state APPTA chapters and state licensure boards.  While the professional organizations challenge the status quo, advance baseline knowledge, grow the profession, and are generally the more “sexy” of the two sibling groups, licensure boards are charged simply yet profoundly with the responsibility of protecting the public from harm while receiving care.  Professional regulatory bodies hold and advance the profession’s “bottom line” or, as I like to think of it, playing defense to the professional organizations’ offense.  The voice of the patient is so important in regulation of practice that at least 1 unlicensed and independent public member is included on each state board (important arguments have been made to include more – slow process to change practice acts).

My purpose here is to question and challenge the factors currently influencing your professional trajectory.  Maybe more accurately, to challenge you (and remind myself) to continuously question these factors.

  • How does this CE course allow me to better address patients’ needs (expressed or unexpressed)?
  • Does my employer (actual or potential) allow me to respond the voice of my patients?
    • An important consideration in becoming your own employer too.
  • Does my practice setting (current or potential) provide the best gateway for me to serve and deliver real impact to the benefit of the patient?
    • Would also apply to promotion or change in role.
  • What does the voice of the patient (the voice of your own patients) say in response to this professional decision (in the clinic or for your career)?

Some Final Thoughts

Professional organizations and regulatory bodies are not opposing forces.  Rather, two components in the effort to elevate the standard of care.  Get involved with your state board and volunteer with national bodies like the FSBPT.  Stay involved with your professional organization.  Keep the patient the center of all of it.

Still Writing

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Hi,

In case anyone is looking for more Voice of the Patient content, it’s coming.

I’ve been doing a lot of more technical writing in preparation for the Interstate Physical Therapy Compact.  When that is published (through the FSBPT) I’ll be sure to link to it.

In the meantime, please be sure to stay in touch with your state professional organization and encourage them to introduce the compact to your state legislature this term.  With any luck, by the end of 2017, the compact will have the 10 members required to initiate the rules-writing phase.

Dave

 

The Voices of the Patients

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Im calling on clinical folks to listen, not only to the voices of their patients, but also to one another.
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Since January 20th (some could argue since November 9, still others would argue since January 20th 2008… and the argument devolves from there), the discourse in mainstream & social media seems to have plummeted.  We’re no longer talking about “the common good.”  Rather, I’m seeing and reading an almost scary fascination with painting any who oppose a particular viewpoint as evil incarnate.  As one side raises the intensity, the other sees and raises in kind (or unkind as it were).  Quite simply, we’ve corporately stopped listening to anyone’s voice who opposes our own.

Drown out in the sea of arguing are the voices who can’t, don’t or just won’t shout others’ down.  These voices want to be heard also.  For these, convictions are no less strong and needs no less emergent.  The recognition that each is a valued part of a stronger whole which is better together than separate is our bond.

But what does this have to do with The Voice of the Patient?  It’s not a political blog… is it (angry face emoji)?

In the on-going national debate on healthcare, we agree on the destination: Achieving optimal health for the individual –> the community –> society as a whole.  We may disagree on the path.  A now old-fashioned concept that we might thing about dusting off here is “compromise.”  We used to be able to introduce an idea and it wasn’t a personal affront.

As clinically minded people, outside of the whirlwind of politics, we’re entirely focused on our patients’ care and will go to bat for them at any cost.  I’m calling on clinical folks (PTs like me, MDs, DOs, RNs, DCs, etc…) to listen to the voice of their patient.  I’m also calling on us to listen to one another with the exact same intention – “I respect you as a person.  Though I may not care for your opinion, I will not assign this dislike to you as a person.”  In practicing and living this way, I know we can make so much more progress toward the goal above.

The truly grievous part is that we, as individuals and as a country, have the means and opportunity to come together, serve one another, and be stronger in the end.

The Pain Scale and The Voice of The Patient

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“On a scale of 0 to 10, what is your pain?” 

For quite a long time, I would have answered the pain felt when asking that question was somewhere in the neighborhood of 8 or 9.  More recently, I’ve challenged myself to take another look.

At the start, it needs to be acknowledged that there is nothing purely objective about the pain scale.  The subject is asked the question and, as a subject does, subjectively replies.  Is there any redeeming quality to the question?  Is anything being accomplished besides checking off a box on the evaluation form?  This question, even when the answer is “15,” gives us a peak behind the curtain.

Too often, the emotional component of pain is neglected in favor of the much cleaner tissue damage aspect.  The pain experience, at least in the patient’s mind, is framed by the emotional circumstance of the episode.  Sure, the sensation isn’t great, but it’s often the inability to do something important to that person’s life that serves as the driving force in seeking treatment and ultimately relief.

And so we’re back to our friend, the analog scale.  Often, when we’re asking the question, we’re looking for an objective measure of the pain.  However, if we’re listening to the patient’s voice, we’ll hear a measure of the impact the pain is having on their lives: 3-4 – “It’s pretty annoying, can you make it stop?”  9-12 – “This sucks!  I can’t deal with it anymore.” 

It may be a subtle difference but it’s an important one to make.  It’s the difference between wasting some ink checking off another box on your form and hearing the voice of your patient.