The Patient’s Perspective

Knowing what patients are thinking and saying about your Practice is an important aspect of patient management, which is rarely discussed amongst professionals.  On our first patient encounter we have no idea of their historical beliefs about Physiotherapy, their expectations, their fears, their level of compliance, their commitment to finding a definitive solution, their financial circumstances or their social environment.

On initial reflection our initial impression maybe that we cannot influence many of these variables because they are either outside our remit, outside our scope of practise or simply beyond our control.  Previous posts on this blog have referred  to psychosocial flags and extrapolated beyond the well known Red and Yellow flags to the more recently updated concept of Orange, Black and Blue flags.  If you are rusty on what those definitions refer too you can review them here and here.

It raises the very contentious issue of defining what variables are modifiable and which are not. This is contentious because Health Economists tell us repeatedly that education, socio-economic standing, geographical location and social structure are predictive factors of the utilisation of Health Services.  These factors are also strongly associated with poor outcomes, which then raises the obvious question – why bother?  In my own working environment, which is a Private Clinic, patients either self-fund or are reimbursed by a third party payer.  I naively thought many years ago that patients who were paying for treatment would be more motivated to achieve a rapid resolution of their situation and demonstrate enhanced compliance with recommended regimes.  Twenty-two years of experience, with twenty in the private sector, has convinced me that this is not the case.

However, I have concluded that patient expectations of a solution are certainly high in this environment – but that does not always translate into shifting the locus of control from the clinician to the patient in terms of compliance.  Perhaps it is a case of patients paying and therefore expecting the solution to be passively provided?  Whilst it is undoubtedly a pressure which clinicians in this environment will be aware of, it is frequently an untalked about subject and not particularly conducive to developing a good therapist/patient relationship when the initial discussion approaches ability to pay.

My dentist colleagues suggests that not discussing money at the outset of treatment is indicative of a lack of confidence of the therapist and a self-depreciating view of the value of the service provided.  Whilst this maybe one explanation I would contend that the Public’s perception of good dental hygiene – having the “Hollywood” smile is probably far more pervasive and well established than having optimal musculoskeletal health.  Dentists have shifted their paradigm from being “tooth extractors” to being preservers delivering prophylactic care and self enhancement services. I am still of the view that most patients consult physiotherapists when something has failed rather than to enquire about musculoskeletal health. We have a road to travel in this department.

On this basis the value that is attached by a patient to Physiotherapy relative to Dentistry I suspect is somewhat different unless they have had positive previous experiences.  Ultimately it comes down to individual choices and I have never come across a patient who has terminated their satellite TV subscription service, stopped smoking or reduced their frequency of pub visits in order to fund Physiotherapy.  Of course this may have happened without formal discussion but I suspect it would be a rare circumstance?

How frequently in clinical practice do you ask if patients are satisfied with the service  they are getting and whether it is meeting patient expectations?

Do patients get the message that you are satisfied with the rate of progress?

If patients have plateaued or are failing to respond are you comfortable approaching this subject in the knowledge that it is the pathology hindering resolution rather than therapist inadequacy?

Or is it a skill deficit?

This leads us then into a terrain which we have previously discussed regarding defining the patient’s prognosis and either confronting the issue of a poor outcome or making rational decisions for onward referral to other health professions who can be of practical assistance.  It is far to frequent an occurrence for Physiotherapists to send the patient back to the G.P. or for surgical consult when these strategies do not influence the practical management but simply abdicate the therapist from having a frank (and potentially unpleasant) conversation with the patient.  If we want to be respected as a profession we need to bear this responsibility as part of our duty of care.  We will return to this issue in subsequent posts no doubt.

Enjoy the clinical challenge

David

GHTime Code(s): fba08 b7bcf nc 

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