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.