I’ve just had the great pleasure of listening and speaking with legendary All-Black rugby captain Sean Fitzpatrick. See: www.balls2business.com for Sean Fitzpatrick’s story and valuable information.

The conference was for clinicians and the theme of Sean’s talk was how to transfer the lessons of successful sports teams into clinical practise. Being a huge rugby fan it was great to meet a living legend but I was also really impressed with the message (as well as the messenger) and found it inspiring.

It got me thinking about applications to Physiotherapy and below are some thoughts based in Sean’s presentation.

What makes a global brand? What sets it apart from all other brands? How can lessons be learned from the All Black brand and applied to your own business?

The role of branding applied to physiotherapy can be considered in terms of the public perception of what physiotherapy has to offer (ie What is it?) or more specifically how it relates to the individual organisation/hospital/practice in which we conduct our business. The public perception of physiotherapy is very much based on their own interpretation or second-hand information unless they have been in a position where they have had previous care administered to them or a relative. Therefore, there frequently isn’t a yardstick by which to measure the competence of a therapist other than looking for familiar clues of ..

Professionalism

Communication skills

Personal presentation

Effectiveness of treatment.

Essentially patients are looking for solutions to problems and generally are not concerned about the clinical challenges which clinicians wrestle with in order to deliver optimum care.

I must confess it has taken me far too long to realise that the technical aspects of the job are only part of the essential core skills required.

“When the All Blacks win, I’d much rather be the All Blacks captain, and when they lose, I’d much rather be the prime minister.” Jim Bolger, ex-Prime Minister of New Zealand. How do you lead the All Blacks? How do you lead?

Again there are multiple levels to apply the analogy of strong leadership in physiotherapy practise. Those in a leadership role must communicate their vision and ensure that staff entrusted with delivering care are comfortable with the vision and it is consistent with their principals. It goes without saying that leaders should lead by example to have any credibility.

On an individual basis if we think about the qualities employed by effective leaders they would include..

Seeking advice

Collaboration

Decisive decision making

Implementation

Evaluation

Feedback

all of these concepts are equally applicable for a patient care plan delivered by a sole practioner – as Sean Fitzpatrick says “be the best you can”

The basis of sporting excellence is all about identifying, maximising, and then utilising your strengths. Find out how this is achieved in a sporting context, and how to transfer this understanding into your business.

No one can have all the answers. Recognising our skill limitations and the possibilities of better treatment options from other care providers is sometimes a humbling experience for a therapist. However, leaving aside the associated personal challenge our fundamental objective is to do what is best of the patient. If often seems these lines get blurred in daily practice. “Do what’s best for the patient” is a mission statement to start every therapist’s day.

Developing and implementing a plan to win a World Cup brought with it lessons and insights that might prove highly useful to those responsible for business planning.

As the saying goes “failing to plan means planning to fail.” As therapists we must have a clear vision and process of how we intend to pursue treatment and its delivery to a patient. We must also have a clear plan of recognising when our strategies are not being effective and need to be altered. Far too often patient’s failing to respond is transferred into blaming the patient for non-compliance rather than therapist self scrutiny.

Things to consider are..

Poor planning

Poor treatment delivery

Failure to recognise the potential limitations of the pathology

Failure to match expectations with reality

Sometimes the business requirement is to take the direct line, tackle the issue full-on, head to head. What can we learn from crash ball rugby about when – and how – this tactic can work best?

There are undoubtedly situations where clinicians have to take a chance and take risks As long as these risks are not reckless but calculated they are not negligent. The outcome may not always be positive, but if you don’t try you will never know. Fear of failure leads therapists to avoiding clinical decision making. Telling a player to return to a club training session with advice to “take it easy” instead of testing functional tolerance in a controlled environment or defining the boundaries loading parameters is an example of this. Having a patient “breakdown” during rehabilitation is not a pleasant experience but engineering this breakdown to happen away from the clinical environment is simply looking the other way! We need to take responsibility.

In 1986 a young team including thirteen debutants travelled half way round the world, and beat the reigning 5 Nations champions. How was this achieved? Succession planning…

Planning for continuity of care is the most obvious example that springs to mind. No matter what detail is recorded in clinical notes a 1 minute conversation between therapists can be more effective than hours of reading. Establishing a bond is a critical part of delivering care and drawing on the experience of face to face contact time is invaluable.

For example

Knowing there is an important upcoming competition

Knowing there are concerns about serious pathology

Wondering if things will ever get better

Conflicting information from healthcare providers

This type of detail not usually recorded in clinical notes but vital to shape the patient – therapist relationship.

Would you rather watch a team play beautiful rugby and lose, or watch a team grind out a win? And (whichever answer you give) which one would you rather play for? Is your business about process, or outcome?

Simply put as therapists we can get pre-occupied with technical aspects and new technologies but we need to constantly remind / test and re-test our interventions to ensure our work with a patient is effective. I’m old enough to remember using short wave diathermy and heat lamps for hours without any tangible measure of benefit. We have to make our contact time count!

Unfortunately, there isn’t a ready-made recipe. But this module includes a set of thoughts and insights from one of the great team leaders of one of the great teams in sporting history. What are the dynamics that you have to consider in order to get a collection of individuals to perform as a team at the very highest level?

The team can be within a department / practise or the wider application to multidisciplinary healthcare teams. Having “outsource” options for surgery, pain management, rheumatology, psychology, pharmacology are all necessary components of musculoskeletal pain management. Having confidence in the clinician is absolutely critical to deliver effective care.

I’ve lost count of how many times a treatment plan has been sabotaged by…

Dismissive comments

Trivialisation of symptoms

Flippant remarks

Superficial examination

Disinterest

Abrasive language

We need to know the team members if we are to have confidence in them. We don’t have to like them – just respect their clinical judgment. Matching the personality to the patient and be very valuable in the right circumstances. For example, an abrupt neurosurgeon dealing with an acute surgical disc prolapsed is far more acceptable than in a chronic pain management situation. A holistic pain specialist is more appropriate than an invasive pain specialist for a patient who fears needles!

I’m sure we’ll come back to this post in future and drill deeper into the points raised.

Some powerful lessons that we need to integrate into our practise.Please share your comments and opinions.

Enjoy the clinical challenge

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | 2 comments | Add to del.icio.us
Post tags: chronic disease, clinical examination, detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, pain questionnaires, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, peak performance, persistent ongoing symptoms, physiotherapy, Previous response to treatment, primary care, professionalism, prognosis, psychosocial flags, quality assurance, sean fitzpatrick, subjective questioning, targeted therapy, therapist credibility, Type of interventions prescribed

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As clinicians we have been bombarded with research outlining the important role of psychosocial issues in clinical outcomes.  I have often wondered why these models have been applied to low back pain and whiplash but don’t seem to feature on the radar of many other chronic conditions we  see routinely.  Maybe it’s a case of chronic conditions such as osteoarthritis, ankylosing spondylitis, degenerative joint disease etc having more defined pathology and are therefore being a more acceptable diagnosis to patients thereby deflecting them from further questioning or seeking more treatment.

Regardless there is a vast array of measurement tools available for quantifying

psychosocial components. These include:

McGill Pain Questionnaire

SF36 Health status Questionnaire

Oswestry LBP Disability Questionnaire

Fear / Avoidance Index

Pain Catastrophization Index

Visual Analog Sacale

to name a few.

Taken in conjunction with the now widely accepted concept of Flags;

Red

Yellow

Black

Blue

Orange

we have a huge battery of questionnaires and a framework which can be used to elucidate individual characteristics and tendencies.  I have spent several years enquiring about the merits of these scales in primary care and arguing that specific questions interspersed within a subjective examination yield more direct information than a “profile questionnaire” yielding information about individual tendencies. For example “when are you planning on returning to work?” will yield some specific answers ranging from “never” to “when you get me better” to “when they say their sorry” etc…. Such responses present the clinician with an opportunity to challenge beliefs, identify obstacles or alter a management plan. Several authors of these tools acknowledge the basis of this argument but cite the lack of “research validity” for the approach I’ve outlined. I’ll let you be the judge of that!!!

One of the big challenges in an acute presentation is whether to initiate these type of investigating tools as part of a routine assessment protocol or whether to try to identify high risk patients relatively early in the intervention and alter management strategies accordingly.  On the face of it this might seem like an obvious management plan but there are some very real practical limitations to implementing it.

Firstly – if every acute patient is going to be screened using psychosocial profiling from day one then there are large numbers of patients who are going to be asked a lot of questions which they may perceive as being highly irrelevant to their primary (musculoskeletal) problem and the reason they consulted Physiotherapy.

I think this is particularly significant in the Private Care Sector where we deal with patients who are unlikely tolerate some of the enquiring questions contained in the questionnaires and the  perception of the type of treatment to be administered .  Remember again we are talking about an acute setting here not a chronic pain management setting where the patient mindset is in a different place.

Secondly, the challenge if we wait for recognition signs of slow response to treatment or unpredictable features which emerge as part of one-to-one contacts, three or four sessions into care, is how do we change our management strategy and sell it to a patient in a credible way?  By “selling to the patient” I mean providing a credible explanation for their symptoms, which may be contradictory to what was initially stated, based on the physical findings alone on initial assessment.  This is a major major issue, which is never discussed in formal literature but as clinicians, one which we must find practical strategies to address if we are to be in a position to deliver care.

So the issue of therapist credibility surfaces in two respects: Firstly,in that the explanatory mechanism of a patient’s symptoms may need to change as the therapist gets more information from increased patient contact time and behavioural observation.

Secondly, how do we start to change our rating scale factors to shift the hypothesised mechanism of symptoms from being nociceptive to more predominantly psychosocial?  Of course as in all things in life this is never a clear cut classification as there will be degrees of pain mechanisms in all presentations which may alter and vary as time goes by – ie they are dynamic.

We have discussed pain mechanisms in previous posts. So how do we rise to this challenge of changing our clinical hypothesis to facilitate a different management strategy and delivering that message effectively to our patients in order to achieve compliance?  This again is another un-talked about subject.  The therapist can feel assured in the knowledge that they are following International best practise guidelines to deliver a message which appears entirely credible to the therapist but does not appear so to the patient.  This is a classic situation of “blame the patient” for not listening to the message.  The challenge for the clinician therefore is to recognise early signs, which require a change in the hypothesis of symptom mechanisms. It also means careful consideration of the type of clinical discussions which occur in the early phases of a patient /therapist interaction. (and I don’t mean being “wishey washy/vague” when reporting clinical findings – just systematic and analytical).

Below is a checklist of strategies which maybe helpful in the clinic.

1 Be familiar with the content of international guidelines on management of acute LBP.

2. Develop an opinion o these guidlines (ie agree, disagree or select elements)

3 Evaluate the type of patient you are dealing with (ie tense, easygoing, enquiring, intimidated, hopeless, unrealistic, naive, diligent, self directed, victim etc…)

4 On the basis of your evaluation above be selective about the type of words used to describe symptoms.(ie  pain v’s symptoms, problems v’s disabilities etc).

5. Avoid the pitfall of” information overload” in patients who won’t / can’t process this.

6. Avoid , at all costs, the pitfall of” information overload” in patients who will mal-process / distort the information presented.

7 Be guarded about contradicting professional opinions which are contrary to your own (even if you think they are off-the-wall”). Careful dissection of inappropriate advice needs supportive analysis, not dismissal, and is the difference between alienating a patient and keeping them on board to deliver care.

8.Identify predictable /familiar elements of pain patterns which responses can be mapped.

9. Identify clinical /subjective response characteristics which are improving from treatment – even if the overall patient perception is of “no change”.

10 Eliminate / reduce “Nociceptive” pain mechanisms ie clinical signs of pain, stiffness, muscle spasm, loss of movement before concluding an alternative symptom mechanism (psychosocial). Blaming all symptoms on stress, tension, strained relationships, smoking, excessive weight is a sure-fire way to lose credibility.

I think there are a few more points to add to this list but that should suffice for some mental marination.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | One comment | Add to del.icio.us
Post tags: chronic disease, clinical examination, detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, pain questionnaires, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, persistent ongoing symptoms, physiotherapy, Previous response to treatment, primary care, prognosis, psychosocial flags, subjective questioning, targeted therapy, therapist credibility, Type of interventions prescribed, whiplash

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Equally important is the identification of patterns of symptoms, which do not appear directly related to mechanical factors which are potentially intractable and unresponsive to physiotherapy.  The delicate balance to be struck here is whether to pursue legitimate treatments which have some realistic possibility of producing significant improvement, countered against the potential for giving the patient false hope with the consequent negative impact of yet another failed intervention.

What factors constitute significant improvement?

Now there’s a topic for another day!!

Factors determining information delivery:

Previous response to treatment

Type of interventions prescribed.

Patient expectations

Patient confidence in care providers

Patient attitude towards collaboration between the care providers (hostile, enthusiastic, detached, despondant)

Patient attitude to the level of disability associated with their condition.

At the other end of the spectrum are patients who present with  acute symptoms  in “high risk” areas – where know there is a strong propensity for chronicity (whiplash and acute low back pain). There is a delicate balance to be struck between trivialising modest physical findings and associating them with a short response time.  This of course fatally damages the therapist’s credibility if the symptoms have not resolved within the predicted short response time.  Alternatively, stating protracted recovery times or extended periods of disability may well become a self fulfilling prophecy.

In this situation the way to manage all acute presentations is to have structured milestones and goals in order to assess the rate of progress.  If this format is applied then patients who are responding at a slower rate can be recognised early and the therapist can equate the level of progression observed over time with the sequence of stages required to achieve full return to function.  This is not the same as telling a patient it may take a year to get better but they are unlikely to see improvement in a given specific functional deficit if they still have symptoms or discomfort when challenged at a lower level.  Therefore, equating functional tolerance with symptom characteristics is an important yardstick for both therapist and patient to monitor.

Enjoy the clinical challenge.
David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | One comment | Add to del.icio.us
Post tags: detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, persistent ongoing symptoms, physiotherapy, Previous response to treatment, prognosis, targeted therapy, Type of interventions prescribed, whiplash

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