A pitfall of patient-centered communication

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I’ve come back from physician visits without a clear idea of what my physician thinks. I think I’ve found a problem, and I believe it’s communication. 

The push to be patient-centered and take all patient preferences in to account has morphed in to a wishy-washy communication style which boils down to the clinician saying “Well, whatever works for you. What do you want to do?” This, in turn leads to conversations at home with spouses and friends of “I don’t know, I wanted my doctor’s professional opinion and they told me I could do what I want. They gave me options but not direction”

This is not good for the patient. The correction away from paternalism, and towards taking patient preferences in to account, to allow shared decision making has clinicians on edge about making professional statements about the next options. I want to know what you think. Then I can bounce that off my own preferences. Don’t take my preferences in to account before you give me your opinion.

If you give me your professional opinion, we might disagree. So there is risk there, in today’s world. That does not help your Google reviews, or Yelp status. If you give an opinion you might loose me as a patient, or I might say “all you wanted to do was give me medicine!” So you couch your answer and say: “Well, you could do this, or maybe this, it’s up to you, you let me know.” This might work well with some things (“would you rather complete deadlifts of glute bridges””) but not others (“we could do another imaging test and see, or you could have this procedure, or wait to have another test”).

How about you give me some data, some outcomes percentages, some risk and benefit data. Then state what you think my next step should be. I can shop to the next clinician and she can tell me her ideas. Then I’m informed. Now I can use my preferences.

It’s patient centered to give people the facts, and to give them your view of the situation.

As clinicians we are perhaps concerned about alienating the pro-magic essential-oil crowd, or alienating the pro-procedure give-me-all-the-things crowd, or the I-already-know-what-I-want-from-you crowd. The Alternative “Medicine” provider does not shy away from recommendations. Professional science based practitioners should not either. We need to speak and explain what we think. Sorry, you might loose a patient if your plan does not fit with them.

I’m not purporting that the conversation end after you state your case. I would like to see a swing to a fearless conversation on both sides of the patient and clinician interaction in an honest and safe manner. Not all health care decisions are easy, so there is certainly room for grey areas and contemplation, but I’d like to know what my health professional thinks. And we should apply this to our own clinic

So work on this next week as a clinician. Strive to state you case, then find out what the patient thinks about it. They’ll appreciate your position and appreciate you asking them their thoughts. 

That’s my position. Thoughts welcome.

Matt D

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9 thoughts on “A pitfall of patient-centered communication

  1. For anyone further interested in this – you should check out Gawande’s “Complications”. Specifically pages 210-227. It discusses paternalism and the shift to more patient-centered decision-making to somehow finding that important middle ground.

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  2. Most patients come to physical therapy for a specific reason. Something is limiting their functional abilities. It might be pain. They may have had a neurological insult. It could be post surgical. In all cases your advice/treatment is based on your evaluation. Post-op patients usually have a defined protocol. Your approach tends be more paternalistic because you and the patient must follow a protocol.
    With pain and neuro patients things are a little more open ended but the patient is still looking to you for specific advice. It’s like when you take your car in for a tune up. There may be some discussion about service but the mechanic is the expert and knows what needs to be done. When I evaluate a back pain patient, I explain deficiencies and their relevance as I find them. Then, with a spine model and pictures, I’ll summarize the finding and explain what needs to be done. Is that paternalism or being an expert?

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  3. Paternalism seems to have become a bad word but at the same time you complain that your physician doesn’t give you enough direction. I would opine that PT’s and other healthcare professionals need to be paternalistic on a sliding scale. There are some clients that need a drill sergeant with strong direction and others that need paternaiism-lite. Either way, the therapist directs the course of the sessions. I’m not saying there is never any discussion but to get things done, the therapist runs the show.
    Also, clinical PT’s are mechanics. We are movement specialists. Everything that we do is based on kinesiology which is the study of the MECHANICS of human movement. Everyday you use your knowledge of human mechanics to correct pathomechanical problems, like poor quad responsiveness. We try to change DIMS to SIMS. Being called a mechanic is not a demeaning term, it is a compliment.

    Lastly, last year I responded to Spencer’s blog in Feb 2017 which featured Dr Jevne’s quote about cars and mechanics. Apparently, Dr Jevne doesn’t know very much about automobiles or the people that work on them. There are many parallels between cars and our human machines and between PT’s and auto mechanics. I tried to give an overview in my response back in February.

    Matt, I hope that you take my comments in the spirit in which they are intended. I want to offer a different perspective so that we all might improve how we practice our profession.

    Brian

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    • Sure, thanks Brian. You’re very much in the majority of how many PTs think, the mechanic part, the pathoanatomical part. I get where you are coming from. But this is off topic, as this is rehashing some prior subjects about the links between disability/pain and mechanics etc. Like you said in 2017 🙂

      I just want to know what my clinician/provider/MD, etc thinks first. Honest. And then I want a discussion of how that fits with me and my wishes. Patients are the same. There has been a strong pendulum swing towards patient centered care (as we used to be paternalistic/authoritarian) which has been a very good thing. This shift can lead to pandering and avoiding tough discussions or being fearful of a poor satisfaction survey. The post was meant to remind us not to swing so far that the patient does not know our professional opinion in an attempt to be patient compliant. I get what you’re saying about types of patients that respond to direct advice vs wanting to add more input. But I don’t think you’d like the definition of paternalism to describe how you interact.

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