A recent discussion with a colleague brought up an intriguing aspect of the patient-practitioner relationship. Do practitioners put pressure on patients? It is common to outline expectations for treatment outcomes such as ‘I would expect this problem to resolve with 3-4 treatments’ ‘You should feel a lot better 24-48 hours after today’s treatment’.
You will know that patients are impressed when clinical predictions are correct and they do respond as expected but this is not always the case. Have you ever considered that it might be quite difficult for some patients to come back and say ‘I am not feeling any better.’ For some patient’s this won’t be an issue at all but for others it is difficult and there could be several underlying messages:
‘You were wrong’ ‘Your treatment didn’t work’
‘I’ve let you down by not improving as you expected’
‘You’ve let me down by not providing effective treatment’
There can be a sense of failure and disappointment on the part of both the practitioner and patient.
We know that pain is a complex subject and the majority of patients visiting practitioners are experiencing pain. With pain being centrally driven and fuelled by multiple sources it is not surprising that physical therapy treatments will not always produce the expected outcomes.
When a patient returns who has not responded to treatment as expected there can be a process of ‘blame thoughts’ on the part of both the practitioner and patient:
‘The practitioner’s treatment has not been effective’
‘I’m never going to get better, my injury is too bad’
‘The practitioner does not have the right diagnosis’
‘The patient has not followed the advice I have given them about exercise and posture’
‘Do I really know what I am doing? – is my treatment effective? Do I have the right diagnosis? Would my colleague be more ‘successful’?’
And I am sure you can come up with many more thought processes that may arise in this situation.
How should we respond?
The initial approach is to try to avoid the feelings of failure and disappointment in the first place. As part of your dialogue with your patient outline your expectations but also include a ‘sub-clause’ allowing your patient to know it is ok if they do not respond as expected. Keep your patient informed at all times of your understanding of their condition and treatment outcomes. Educate your patient on why they may not respond as expected and other treatment options. Make sure your patient has realistic goals – a step-by-step approach to improvement rather than expectations of a ‘cure’.
Reassess the patient and make sure the diagnosis is correct. Try to understand any underlying factors contributing to their condition and pain experience. Make sure your patient is happy to continue with treatment.
Patient’s with long-term conditions may be very satisfied with achieving the goal of being able to walk for 10 minutes before pain comes on. As practitioners we can have goals far beyond our patients and that can lead to putting undue pressure on patients. If your patient just wants to be able to walk comfortably to the paper-shop allow them to enjoy reaching that goal. These are complex interactions and all practitioners would benefit from reflecting on this aspect of practice and achieving a greater understanding of our own thought processes, expectations and the pressures we place on our patients.
As a practitioner guard against negative thought patterns. Yes, re-assess and make sure you are taking the right approach but don’t lose confidence in your clinical skills. Remind yourself of all the patients who respond well to treatment as expected. Enjoy the challenge and variety of your work – thankfully not all patients are predictable and that is one of the elements that stimulates practitioners in their day-to-day work.