Don’t Beat Patients with the Science Stick

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Let’s start with a few basic principles:

1. Do no harm.  Ever.
2. Providing care with an evidentiary basis is absolutely preferred above the alternative.
3. Healthcare can no longer be only a series of passive modalities (physical, medicinal, etc.. included).
4. In the case of an exception to principles #2 and/or #3, principle #1 CANNOT be violated.  Ever.

For the science-y types, please understand that I agree with your assertion that we must continually question our own and one another’s treatment approaches reducing dependence on modalities that have been tested and shown to have minimal to no clinical effect.  Likewise, we must be open to our practices being challenged.  Feelings properly checked, let’s get after it.

The rule of thumb I use in the clinic is this: I cannot charge a client for a service they could otherwise get by purchasing a product through Amazon.com and applying themselves.  Ultrasound and TENS are good examples.  This is not skilled care.  My skill is in the application of anatomy/physiology, tissue healing, biomechanics, etc… to the neuro-musculo-skeletal systems.  I will charge (plenty) for that.  It’s my opportunity to help my patients see that value and want to pay for my services.

Sure, there are certainly shady people who will continue to make a great living off of peddling passive modalities unsupported by evidence as “physical therapy.”  These patients eventually change providers and wander into our offices… expecting the same care, but different results.

The awesome, blog-reading clinician you are, have the opportunity to do something that, apparently, no other clinician has ever done with/for this poor soul.  Talk with them.  More importantly than talk, you will LISTEN.  In listening, you’ll understand they’re not asking for the junk prior PT peddlers have sold them.  But breaking out of a comfort zone is… uncomfortable.  Here’s my advice:  

Hold their hand.  Be their partner.  Earn their trust.  THEN change their expectations.

Mr. Jones:        “Ultrasound [cupping/whatever] was the only thing that helped when I was in PT before.”

You, PT:          “Studies show ultrasound [insert alternative modality here] doesn’t work.”

–> You’ve effectively slammed the door, ruined your opportunity to effect therapeutic change, and FAILED to address their core concern.  Bust out your microscope to view your chances of that patient completing the POC you’ve carefully lain out for them.

Mr. Jones:        “Ultrasound [cupping/whatever] was the only thing that helped when I was in PT before.”

You, PT:          “What were you able to do when you could walk better?  How did that change day to day life?”

“Since you’re in for the same thing, would you mind if I tried something new?  I want to help you get the relief you’re looking for and find a permanent solution for you so you can do XYZ.  Doing too many different things [you understand: independent variables] at the same time can make it difficult to tell what’s making the difference.”

“I’m open to adding [crappy passive modality] later if we still need it.”

[Consider some pain science bombs here]

–> Congratulations.  The door has been kicked open.  Work your scientifically validated magic.

Full disclosure, I have not given (or assigned anyone to give) an ultrasound in over 2 years. I’ve given fewer than a handful in the last 5 years; only after a similar conversation as above and more because I felt that there was a therapeutic “wall” in that specific patient’s mind (where pain is synthesized) convincing them that this was the ONLY treatment that would work for them. That wall could ONLY come down with a solid relationship. Most of the time that psych component can be addressed with solid, empathetic discussion and education. Other times, it needs a magic wand/ultrasound. We’re doing no harm while aiding that patient past their barrier.