I went to the dentist the other day for a routine exam and cleaning and it reminded me what being a patient is all about. In a physical therapy clinic, just like in any work environment, it is easy to become habituated to your setting and think that it is perfectly normal to…

• Use terms like “manual therapy” “isometrics” and “glenohumeral joint”
• Assume that everyone knows that they should wear athletic shorts and sneakers to their physical therapy appointment!
• Think it is perfectly reasonable to ask a patient to immediately incorporate 15-20 minutes of exercises into their daily routine
• Touch various parts of a patient’s body in order to assess and treat muscles, bones, joints…

…But, being a patient in a novel healthcare setting (the dentist), automatically put me in a very different place. I found myself uncertain about some of the requests that were being asked of me and uncomfortable with some of the assumptions being made about “what was best” for my dental health. It really made me start to evaluate closely how I communicate with patients and reflect on if my care was really as “patient-centered” as I intend it to be.

A recent BJSM article (2019) on best practices for treating musculoskeletal pain (joint, bone, muscle pain) lists “Delivering Patient-Centered Care”as the #1 recommendation (out of a list of 11) on how to improve care for patients ² .  For me, this term “Patient-centered” care reinforces the idea that the patient is central to every decision we make: diagnosis, treatment, and referral if needed. Patient goals, values, complaints, desires, and needs should be taken into consideration for every aspect of our care within the scope of our physical therapy practice.

Here are a few thoughts on how achieve this goal of delivering “patient-centered”physical therapy care:

• INFORMED CONSENT: Use informed consent at EVERY stage of physical therapy and at EVERY visit
• SHARED DECISION MAKING: Use shared decision making including assessing a patient’s health literacy
• COMMUNICATE CARING: Use empathic language and give the patient a chance to tell their story

Good communication with patients is exceptionally important in all of these areas, 

and it is absolutely crucialwhen it comes to informed consent.

INFORMED CONSENT:

Informed consent should be obtained during a physical therapy evaluation, but also for any new treatment method and for all subsequent treatment visits. It includes discussing the risks and benefits for any evaluation or treatment technique and eliciting patient understanding and agreement to use that technique.

For a more thorough discussion of the importance of informed consent in the physical therapy setting (both as “best practice” and as a way to protect patient and therapist): check out my PTinMotion (February 2018) article³

“Avoiding Charges of Sexual Misconduct”

OR read my blog post that inspired the article⁴

“Is that okay? The importance of informed consent in healthcare”

SHARED DECISION-MAKING

Part of informed consent is using a shared decision making framework. Patients are seeking out our health advice as it relates to neurologic or musculoskeletal injury. But, patients have knowledge to contribute to the conversation and the patient always knows best how their injury is impacting their life! Indeed, patients want to participate in these decisions and given the choice, patients in one study chose this as the ideal way to make healthcare decisions: “healthcare provider and I make the decision together”⁷ .

In studying to become “movement specialists”, we have become immersed in medical language, jargon, and physical therapy specific terminology and it takes a deliberate effort and practice to explain diagnoses and treatment options in medically accurate, but accessible language. It is very easy to make complex principles sound complicated. But, only the very adept can make a complex pathology or treatment seem simple and straightforward.

One tool that may help with facilitating shared decision making within our communication is the The “Ask me 3 (TradeMarked)” tool⁷ . This tool is also a simple way to assess what has been termed: “health literacy” and using it can contribute to improved patient sense of trust and empowerment in addition to improved health literacy⁷ .

The “Ask me 3 (TradeMarked)” tool guides shared decision making by using the “teach back” method; asking patients to explain back to the physical therapist (or other healthcare provider) their answers and understanding of these three questions as relates to a healthcare visit and discussion:

• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?

COMMUNICATE CARING

This point should be pretty self-explanatory, but I really feel that it cannot be overlooked. If a patient does not trust that you have their best interest in mind, your communication and treatment is doomed to be mediocre at best. Research supports the impact that a positive therapist-patient relationship can have in a rehabilitation/physical therapy setting: demonstrating improved pain, disability, and other outcomes such as patient satisfaction^1,6 . Common themes that emerged from an analysis of the factors involved in positive therapist-patient relationships were: listening, empathy, friendliness, encouragement, confidence, and non-verbal communication⁶ . The practice of earnestly listening to patients, and allowing them to tell their personal story can really set the stage for a great relationship and team approach to care. I also believe that it is supremely important that we allow ourselves to care for patients as humans (maintaining professional boundaries of course) and I have written a chapter specifically on how alienating healthcare can be when clinicians adopt too much of a “business-like” attitude to patient care (see chapter 7 “Dear Doctor, I Am A Human Being” from “Moments From a Year of Healing: A Book of Memories and Essays”).⁵

“No one cares how much you know

until they know how much you care”

– Theodore Roosevelt

References:

1. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Physical Therapy. 2010;90(8):1099-1110.
2. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. March 2019:bjsports-2018-099878.
3. McDaniel LC. Avoiding Charges of Sexual Misconduct. PTinMotion. February 2018. “Avoiding Charges of Sexual Misconduct”
4. McDaniel LC. Is That Okay? The Importance of Informed Consent in Healthcare. SapiensMoves. November 2017. “Is that okay? The importance of informed consent in healthcare”
5. McDaniel LC. Moments from a Year of Healing: A Book of Memories and Essays. SapiensMoves; 2018.
6. O’Keeffe M, Cullinane P, Hurley J, et al. What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. 2016:14.
7. Toibin M, Pender M, Cusack T. The effect of a healthcare communication intervention — ask me 3;on health literacy and participation in patients attending physiotherapy. European Journal of Physiotherapy. 2017;19(sup1):12-14.