Jonathan

How Much Do Patients Need to Know?

James looked at me in a way that conveyed “That thing that you’re thinking, it’s just not right” and I knew a teaching point was coming.

James Lavers is a great teacher of video techniques for personal or brand marketing, and his courses are worth attending for the action they will inspire in you.

I was in London, on the south bank of the Thames close to Tower Bridge, a postcard backdrop to the course during our coffee breaks.

He had asked me something like “What do you want your viewers to do?” and I had answered with “I want them to understand….”

That’s where he stopped me. Then he said something that has always remained with me and informed my physiotherapy practice as well as other parts of my life.

He said “Your patients don’t need to know your expert shit.”

I don’t think I understood the implication of that at the time. I took it as something I should not do, that is to explain things I didn’t need to explain. And that this would make my videos or video courses better.

I’ve been reflecting on that sentence ever since. And repeated it to many people, with proper attribution to James, who most of them do not know.

The real relevance has slowly struck me ever since, and was strongly reinforced when I next visited London.

CFT at the Royal Free

Along with my colleague Neil Davey, I attended Professor Peter O’Sullivan’s last course on Cognitive Functional Therapy at the Royal Free Hospital. The course is always inspiring for the clarity of thought and the practical demonstrations.

The practical demonstrations are amazing! Peter interviews a patient he has never seen before, in front of 300 physios and other health professionals, and shows us how we can help a person change. And they change right in front of us. And the change persists.

Now Peter is a person who has always worn his learning lightly, you never feel any superiority from him although he is clearly more able than pretty much all of us.

This time, however, a new thought struck me as I was walking back to Crouch End with Neil. Peter had seen four patients over a day and at no time had he done any “physio explaining” about pain neuroscience or disc structures or cognitive influences on pain. That seemed new.

He never showed his expertise openly to the patient but guided them towards finding their own ways to change. By showing them that their feared movements or postures did not result in a catastrophic outcome, he made them rethink their views of their body and how it could be safely used.

Do Patients NEED To Understand Anything? Or Do We Need Them To?

Now Neil and I have somewhat different views on this. I’m more of the view that a patient never needs to understand anything about their back or other pains, although I take that position more to limit over-delivery of our technical knowledge than I mean it literally. I think – just show them that the movement or activity is safe and that’ll do it.

Neil is not so sure. He probably has a point.

I’m starting to read the literature around pain education and reassurance, both of which I’m very sceptical about at this moment. But that might change….

Wearing our learning lightly means we don’t let our egos get in the way in showing the patient how knowledgeable we are about this or that subject. It’s just not needed.

In spinal surgery and neurosurgery clinics stenosis is a common presenting symptom. A person over 60 years old complains of leg pain, typically worse in walking and standing and better sitting or bending forward.

In physiotherapy consultations many patients complain of troublesome leg symptoms, and it is unclear whether there may be nerve root involvement.

Leg Pain

Severe leg pain occurs in two main age groups, the 30s and 40s with nerve root compression from disc prolapses and the 60s+ with nerve root compression from stenotic changes affecting the exit canals.

There may be another group however. People may hold themselves in a state of pseudo-nerve compression or joint discomfort due to the way we typically react to back pain and leg pain.

Overdoing the Lordosis

We adopt repeated patterns of posture to reduce our back and leg pain. One of the commonest is the active maintenance of a lumbar arch or lordosis for long periods and in most functional postures. And we carefully avoid flexing our back when we bend over, when we think we are at most risk of back injury.

An increased lumbar lordosis reduces the space available in the lateral nerve root canals and compresses the facet joints. Keeping the lumbar spine in end-range extension could increase the pressure on any nerve root or other sensitive structures in that area.

Functional Stenosis

This is a functional stenosis, the symptoms maintained by continually contracting the spinal erector muscles, keeping the lordosis as much as possible and using a lumbar roll in a chair or a car.

Clinical observation indicates that encouraging a patient to relax their lumbar muscles and to flex forward can improve their symptoms. Backache from maintaining the lumbar extensor muscles in contraction can ease and then the leg symptoms also ease. With routine practice of lumbar flexion in a relaxed manner, the tightness or compression may be reduced enough to lessen leg symptoms.

A continuing focus on a structural tissue interpretation of symptoms and on MRI findings may be leading us to ignore this simpler and more functional issue. Holding the lumbar spine actively in extension could give nerve root-like symptoms and facet joint pain, referring pain to the buttocks, thigh, calf or foot.

Fear Avoidance

Fear underlies the maintenance of lumbar extension. Fear of increasing the pain or aggravating whatever we think is going on anatomically. The McKenzie technique’s ideas on lumbar flexion causing posterior displacement of the disc and thereby worsening symptoms is relevant. Physiotherapists have taken this idea that keeping a lumbar lordosis at all times is vital and that lumbar flexion will worsen symptoms.

Our backs love flexion. Repeated lumbar flexion is good for our discs and our spine, increasing blood flow and relaxing the extensor muscles that are often in perpetual contraction. Encouraging people to perform lumbar flexion is an exercise in reducing the anxiety around doing something they feel would be harmful, or have been told not to do.

There is little evidence that keeping our back straight and bending our knees when we lift is necessary or reduces stress or risk to the lumbar spine. It may do the opposite.

Getting Out of the Way

We could get our of our own way. Our bodies know what to do when sitting, lifting, walking or lying, we just have to relax and let them get on with it. And our job as physios may be to facilitate this change and strip away the layers of protective beliefs and behaviours that many of us build up around our spines.

Many back and leg pain problems appear to be functional syndromes. They are maintained by the actions and behaviours of the person and not related to any particular anatomical abnormality. We should be able to help these people and avoid the ‘there’s x or y wrong with your back’ ideas that excessive concentration on anatomical features leads to. It’s not technical but it takes skill to do it.

Assessments Contract to Fit the Time Allocated.

Recently, a physiotherapist friend did two opposing things in reasonably quick succession.

Time

In the first they complained of not having a good first session with a patient as they couldn’t get to where they wanted to in the time.

In the second their initial assessment with a patient lasted two and a half hours.

We discussed the idea that pushing to achieve a particular goal in the first assessment might have stifled where the session should naturally go.

And as for the second assessment, initially they seemed to think it was OK. But in the next session the patient did say “it was a bit long”.

How Long is an Assessment?

That led me to think how long an assessment should last. Or any session for that matter. And should you have a specific goal, a number of things to cover, a load of boxes to be ticked?

Who should set the agenda for an assessment? Should it be a dry collection of the facts of the case or a freewheeling conversation about whatever comes up?

As a physiotherapist, am I an expert questioner teasing out the salient points, a data collector, a coach, a guide or a supportive ‘friend’?

Having a Goal

Without a goal when we approach an assessment we won’t achieve anything, but how set out, how rigid should that be? When we are starting out we need a more controlled structure to work with, and as we become more experienced we can take a quicker route to our goal.

If we achieve mastery of the process, we should have answered all these questions and come to an expert assessment, clearly seeing the problems and able to move the patient towards a solution.

But how many of us progress beyond the stage of collecting what we see as the facts, going through the list on the assessment form and then emerge as great interviewers?

In his first session, my physio friend had the goal of getting to a conclusion and when they didn’t they felt frustration. The goal was blocking them from allowing the assessment to take the shape it was forming.

The Shape of Assessments

Assessments have a life of their own, and we don’t know where they’re going to take us. At least that’s how I think they should be. When you sit down to assess a patient, if you have only a limited idea where you’re going to be in 30 or 60 minutes this can allow the patient’s narrative to prevail.

The clinician’s skill is to respond to how the assessment is unfolding and help the patient get across all the aspects of their issues. If you let them, the patient will take you on a journey through their life and show you how to help them get better. The assessment forms its own shape and we need to avoid getting in the way.

Cramming Stuff In

The initial assessment often includes the subjective examination, the objective examination, problem identification and a treatment plan.

Mostly this fits into a time allotted. With 15 or 20 minute sessions we will have to direct the patient and get their answers to defined questions or we’ll never get through our list.

Like Parkinson’s Law in reverse, the work is compressed into the time available for it. Having to reach a goal forces us to be rigid in the execution of the interview, and to get to the end at the end.

Targets and Capacity

Demand for appointments, the capacity of the services and the targets set for them all conspire to provide a service which could be so much better. Time is constrained, gradually more and more, to allow more throughput.

Reducing the time for initial assessments could start at 45 minutes, then it seems sensible to reduce it to 30 minutes and then to 20 minutes to get through the numbers.

Outcomes

Without outcomes to tell us how our patients are doing over the longer term, any consultation is of limited worth. We get through the numbers, reduce the list and reduce the waiting times. These things are easy to measure but we are not measuring the things that are important.

I don’t know how long as assessment should be, just that it takes the time it takes to get to a place where the patient feels understood and we feel we know what’s going on. And that should be the goal.

When I think back over all the times me and my colleagues assessed a new patient, and how we mostly collected data within the narrow confines of our questions, I reflect on how that might not have been the best course.

We thought assessment forms were essential, the modern way to quickly collect the information we needed about the case so we could move on to treatment planning. We liked the line drawings of the body, back and front, so we could put areas of pain and other sensations in different shadings, all the ‘x’s and ‘oh’s.

The forms constrained us into asking questions in a particular order and in the style of data collection, as if the patients were passive holders of the data we needed and we just had to get it out.

Fact Gathering Can Get in the Way

Fact gathering can seriously get in the way of getting to the heart of why the patient is experiencing their problems. We don’t need loads of info. At least not at first. Some facts have to be gathered, such as red flag questions, but they will intrude on the process of engaging with the patient’s experiences unless we take steps to avoid this.

Asking many questions, especially if they have yes or no or just factual answers, puts the patient into a passive role. As the patient is the only person who can help themselves, they need to be active collaborators. And they can’t be if we pursue the data collection course.

Professionals such as physiotherapists (or any health worker) can easily fall into this controlling trap, asking closed questions or multiple choices. Either way, this closes down the potential answers and reduces the chances of finding out what’s really bothering the patient.

Dr. William R. Miller, one of the founders of motivational interviewing, says: “If you listen to patients, they say more things about why they want to get better”. And about what is bothering them and how they think they might improve things.

Open Questions Promote Engagement and Share Power

The range of potential responses to a closed question is very limited but to an open question it is extremely broad.

A good approach might be “I’m really interested to hear your story about your back pain, could you tell me about it?”. And then sit back in the chair and listen, without interrupting, for as long as the patient’s flow of their story continues. This allows them to choose any angle and to start at any point in their case history, and it’s likely they’ll start with the things that feel most emphatic for them at that moment.

You’ll find that many of the facts you wanted to gather come out in their story anyhow, and you only need to fill in the gaps at the end.

Open questions mean you’re interested, gives the patient a share of the talk time, a share of the power and changes the depth and complexity of the interaction. Open, evocative questions gives them a chance to open up about their fears, beliefs and experiences which will give you invaluable guidance as to where you need to target any interventions.

If you let them, patients will tell you how to help them get better.

If you’re interested in better questioning, really listening and finding out what patents are thinking and feeling, motivational interviewing training is a great place to start. I did a course on www.psychwire.com and found it very enlightening. I have no financial or other connection with that organisation except as a satisfied customer.

There’s an Alphabet Soup of Physiotherapy Practitioners now.

Physiotherapy has been changing fast in the last ten years. Opportunities for career progression have dramatically increased as the pressures on GPs, secondary services and budgets have grown.

Managers have realised that physiotherapists can do a great number of jobs which were previously the realm of a doctor, can do them just as well and at less cost. No longer do you have to choose a management route to get to the higher levels of the profession, there are many routes now.

This has led to a variety of approaches across the UK as new ideas are attempted, and along with that an explosion in new titles with their very own acronyms.

Extended Scope Physiotherapist – ESP

This title is the first advanced role which was developed in physiotherapy. When it was first proposed that physiotherapists take on roles normally reserved for doctors, such roles were “outside the scope of physiotherapy”.

Once these roles were developed, they were called Extended Scope Physiotherapists or ESPs.

I remember a practitioner in the hip clinics in Exeter in 1989 who was one of the first in the country, reviewing hip replacement patients at six weeks, recording their ranges and checking the X-rays.

ESPs initially worked in spinal and orthopaedic clinics, alongside consultants and registrars. They could order investigations and some could list patients for surgery.

What distinguishes ESPs is that they are mostly diagnostic replacements for doctors, and don’t “do” physiotherapy in the traditional sense. They perform a triage role and refer for physiotherapy if required.

The Alphabet Soup

Since then many new roles have been developed, affecting not just physiotherapy but occupational therapy, nursing, pharmacists and other professions. This has led to a slew of new titles just in physio – orthopaedic practitioner (OP), surgical practitioner (SP), specialist musculoskeletal practitioner (SMP), advanced practice physiotherapist (APP), clinical specialist physiotherapist (CSP), first contact physiotherapist (FCP).

So, with this confusing mass of names and initials, I thought it would be worthwhile discussing some of the recent ideas in physiotherapy roles and the opportunities they afford.

Advanced Practice Physiotherapist – APP

This is now the main name for advanced practitioners, superseding extended scope practitioners as a title. APPs can work in any area, including the Emergency Department, and can diagnose, investigate, inject and refer in many cases.

APPs can incline towards the diagnosis and triage roles (the old ESP role) or towards more of a treatment role where they assess and treat patients with the arsenal of physiotherapy modalities. They also have a significant consulting and teaching role for physiotherapy staff and others, including doctors and nurses.

First Contact Physiotherapists – FCPs

Medicine and allied professions are just as prone to fashion as any other part of human life, and the fashion for FCPs is in full swing at the moment. MSK conditions make up between 15-30% of a GP’s practice, constitute a significant burden and are the realm of expertise of a physiotherapist.

The FCP could see many of these patients instead of the doctor. Evidence shows that patients are happy with this and physiotherapists can safely manage these patients. FCPs work in GP practices, seeing patients with musculoskeletal problems, the vast majority of whom do not have a significant medical diagnosis.

Clinical Specialist Physiotherapist – CSP

CSPs are advanced “traditional” physiotherapists, with specialist skills in examination, diagnosis and treatment. They may also inject and prescribe.

The role of the CSPs, apart from treating patients with advanced skills, is also to promote best practice, support physiotherapy teams, teach and mentor more junior therapists and write and review treatment pathways and patient information.

Physiotherapy’s New World

Physiotherapists have developed several routes to increase their skills and responsibilities over the last ten years. This has included prescribing, injecting and diagnosing in orthopaedic clinics.

By a process of profession creep, physios have been chipping away at the “lower levels” of the doctors’ roles, taking on more responsibility and becoming the independent clinicians we have legally been for some years.

This provides a great opportunity for up-and-coming physiotherapists to make a strong impact in their local medical communities by becoming experts in a particular role or clinical area. This should also free up doctors’ time to make the more complex, judgement-based medical decisions that only they can make.

This process is likely to continue as capacity and cost pressures continue to rise. So if you want a career which takes you into the expert clinical realm, then physiotherapy is now a better option than ever.