You can’t handle the truth?
Continuing last week’s discussions on patient’s satisfaction / disgruntlement I am reminded of a favourite scene with Jack Nicholson and Tom Cruise in “A Few Good Men” about not being able to handle the truth.
Can we safely assume that the normal measures of worsening pathology from a patient’s perspective are:
Signs of worsening Pathology
Increase in severity of p
Slowness to resolve
Resistance to previously successful treatments
Progressive functional impairment.
Expanding area of pain.
This cluster of markers should be used to alert the therapist and need to be incorporated into the report of clinical findings. Incidentally the Chiropractic profession place huge emphasis on the “Report of findings” component of clinical examination – so much so that it is often the main element of follow-up consultation’s preceding initial assessment and examination. One may argue that the motivation here is to get patient “buy in“ to a protracted course of treatment leading to a wellness regime, which is profit driven rather than patient centred – but that’s a discussion for another day.
Suffice is to say that it is considered an essential component in order to establish collaboration with a patient to comply a recommended management regime. As Physiotherapists we are often faced with the clinical challenge of determining the pain generators and the mechanism of symptoms. Frequently this thought process is not relayed to the patient. One can argue that patients only want to know the conclusive findings at the end of your examination but in more recent years they have tried to integrate a discussion on differential diagnosis and indicators for ancillary /elective investigations when necessary or appropriate. I note an increasing trend of blanket testing without rational selection based on clinical findings. This is a symptom of defensive practise, lazy clinical reasoning and wasteful f resources.
Whilst not all patients may need this reassurance it does have the effect of demonstrating that the examination has considered all potential options and drawn a conclusion based on the clinical examination and history. I think many patients find this a reassuring strategy. This does not mean trying to blow the patient away with self-indulgent technical jargon but is a question of balance in delivery using language relevant to the patient (and yes this is a judgement call!). As I have a tendency to over analyse I plead guilty to this on occasion, certainly more so in my formative clinical years but I think I’m cured now?
Another important factor in achieving effective communication of what may essentially be “bad new” is to correlate the functional impairments between previous and current episodes and to define that in terms of known pathologies. This maybe alerting a patient to increasing morning stiffness associated with progressive degenerative change or reduced tolerance for sustained loading i.e. sitting, gardening indicative of changes in tissue biomechanics / intolerance.
For more clearly defined pathology the fall back position of supplemental radiology (largely to confirm a clinical diagnosis) can be helpful but only in the cohort of patients where surgical intervention is being considered as an alternative management strategy. Of course many of the patients we see are at some point along the pathological continuum and may end up as surgical candidates but electing not to do so unless forced.
From a therapist’s perspective identifying and recognising stepwise deterioration in established pathology is important for credibility because promising a cure and failing to deliver has obvious implications for perceived competency. If we add to the cocktail the fact that predicting response to treatment is not an exact science we are frequently left in the situation where we define components of a condition which we think are most amenable to treatment and then set ourselves a target of perhaps three to four treatments to observe useful worthwhile change as a result of intervention. Observing the response over this time gives an indication not only of the potential for recovery but the rate at which it may occur. It does not of course give information as to what the full functional capacity may transpire to be. These are the dilemmas and challenges which we clinicians wrestle with daily and what make this job so exciting. Feel free to share your thoughts as always.
Enjoy the clinical challenge.
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