Thanks AJ for bringing my attention to the title of the article and making me give extra thought to the words. When reading through the section of the paper with the same subtitle A patient in the clinic; a person in the world a powerful quote was made:

“When different clinical groups or different individual clinicians can genuinely disagree on topics in their professional capacities, then how can SDM [shared decision making] fail to integrate an individual patient’s exposure to the wide range of information at her fingertips.”

This was certainly eye opening for me. Expecting a person to come to a goal-setting decision within the initial evaluation and then never change the “shared decision” we made throughout care is not very feasible once you give it some thought. Even with the wealth of educational intervention we typically utilize we are asking the person to make a decision based on limited information and without conversations that are undoubtedly going to occur once they leave the clinic. What I gathered from this except was making sure to not only reassess the person’s objective findings related to our functional goals each visit, but also touch base on their goal themselves and assess their thoughts and feeling on care/progress as time moves forward.

Overall this article was helpful for me, but not for the reason you stated Erik. I actually think we as PTs manage the person centered decision making model fairly well. Personally there is room for me to improve on more frequently reassessing patients’ thoughts and feelings on their goals throughout the plan of care, but I also think this is something most of us are doing on a regular basis, albeit less explicitly. At the beginning of most sessions I typically ask about the patient’s pain (depending on how much the patient perseverates on their pain) and the status of some of their functional goals. For something that occurs every day for the person I think it is fairly easy for me to ask them about how walking/stairs/sleeping have been.

What struck me more about this article was the point made about family and decision making. They mention that some clinicians are actively suspicious of family being present, and I think after a few bad experiences early on, this description fits me fairly well. Just this past week I evaluated a gentleman with his wife present and I noticed that I immediately was off-put by her presence and initially tried harder to not engage her as much in the subjective exam. She ended up being an important resource for information and definitely contributed in a meaningful way to the goal setting discussion. I think that experience and this article really drive home the point to me of the importance of utilizing family as a resource, not as a dreaded barrier to patient communication.

Thanks for sharing AJ. I have always appreciated the concept of patient-centered care, defined as:

Healthcare that is a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions respect patient’s needs, wants, and preferences and that patients have the education and support they need to make decisions and participate in their own care. An important dimension of quality, patient centeredness encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient. IOM Agency for Health

I like how this article challenges us to evolve patient-centered care and SDM to person-centered decision making. The concepts in this article support a wellness model instead of an illness model. It may challenge us to first ask the person a more general question, like ‘how are you?’ before asking about pain and function. Often, much is learned by asking this question.

It also recognizes the reality of the illnesses/impairments/injuries as dynamic, not static, which I think is fantastic. One of my mentors used to routinely use the phrase ‘responding to emerging data’ when she would use clinical reasoning based on the patient’s changing presentation to change course in examination and treatment. I think, too often, in the medical world, a decision is made, then never considered again. There are many examples, but here is one: The prescribing of hormone replacement when it is for the sole purpose of post menopausal symptoms. Many women would only have symptoms for a few months, but stay on the medicine for years without discussing the risks or the continued benefit with their physicians or trying to wean off of the medications. Unfortunately, many patients do not feel like they have easy access to their medical providers in order to follow up and have an open line of communication as suggested in the article.

Can anyone think of some examples in physical therapy where recommendations/home exercises are prescribed, the patient is’discharged’, continues their current program/recommendations without any continued dialogue and the advice which was once helpful later has a negative influence?

One vision of the APTA is for P.T.’s to become providers, like dentists, where instead of ‘discharging’ patients, patients have a P.T. that they see 1-2 x/year for preventative screening/education, then treatment, as needed, for problems that arise. Do you think this idea is more consistent with an illness model or a wellness model? Do you think it would support person-centered decision-making? Do you think it would result in more P.T. visits by a given individual who would otherwise seek P.T. for an injury or fewer visits?

I personally would love to see Physical Therapists become providers and begin to offer more wellness services. Right now we are mostly a reactionary service, treating injuries that could have been prevented with earlier intervention an education. I think there is a lot of benefit from having a regular visit with a musculoskeletal expert, especially with the current obesity epidemic and sedentary lifestyles seen with most people. We are in a great position to cause major change in that arena.

Myra brings up a good point asking whether this would still support person-centered decision making. I think the provider model has the capacity to support or detract from a person-centered decision making process. Ideally, we would be able to see the patient from year-to-year and better understand them as a whole person and help collaborate in the decision making process this way. However, I can see how this model could lend itself to a more paternalistic care approach. I think it would become even more necessary to make sure we explain to patients/persons that we (the PTs) are not fixing their problem, we are empowering them to make change without the continued reliance on our service or any other service.

Going back to the original point I made about the information (good and bad) that people have access to now and the fact that this can cause people to change their minds between visits, think about how much someone’s goals would change over a year. I agree with August, PTs in general do a much better job at seeing the whole person rather than a diagnosis, but there is still potential for Therapists to miss important pieces of the decision-making puzzle.

I think I was just feeling especially cynical after reading this blog post by Roger Kerry about remaining critical of the models we use for care. He recently had a mild backlash to a tweet/twit/whatever about use of the biopsychosocial model and responded with this post.

Myra, I think the best example of a patient receiving a negative influence from an HEP that remains static comes from our discussion this weekend for the lumbar spine and abdominal bracing. I do think that more non-functional stabilization exercises can play a role in our rehab of low back pain, but can understand how too much of that type of exercise or too much of that type of education could have a deleterious effect on a patient’s pain, function, and overall perception of movement. I’m sure plenty of patients are discharged with an over abundance of core stabilization exercises and end up over activating and not actually relaxing regularly. I also could see situations where a set of exercises are appropriate for one condition, say in the shoulder, but with increasing age and continued activity, the pathology shifts on a continuum of injury and those original exercises are now over loading structures.

Similar to what you said Erik, I think that overall PTs being a provider you see 1-2x/year would have a good overall effect, but I’m not sure if it would truly lead to more person centered decision making. You mention dentists as an example of this model, but I don’t think seeing my PCP or my dentist regularly has actually added any great personal understanding that influences my care. Maybe this would be different for PTs or maybe this model just takes longer to yield results, but I’m not so sure that when yearly we see one patient out of a hundred plus other patients that our care would improve considerably.

August – Thanks for your post. I agree with your examples. Another good one.. lumbar extension exercises. I have seen many who started doing them after an injury when they were much younger, who continue to use them as their ‘go to’ at a later age, different MOI, etc. for minor episodes of low back pain without good results. Often, the episode is not bad enough to seek care, but they continue to be ineffective at self-treating until they land back in P.T. with more significant symptoms.

I agree about what you said about your experience with the PCP. Unfortunately, many influences in our current healthcare system have created a situation that is not at all ideal for having a collaborative relationship with our PCP. I have observed that patient’s who are members of concierge medical practices get much better ‘Person-Centered’ healthcare.

As far as dentists – I have learned much/collaborated much with my dentist and feel certain the preventative care I have received from my dentist has been successful at decreasing the magnitude of dental problems.

The benefit I see from seeing people 1-2 x/year on a preventative/educational basis is that you would catch problems when they are small. You can ask them about any small problems they are having and talk to them about their activities. You can then do a musculoskeletal screening examination that is specific to their lifestyle/activities/complaints, discuss preventative strategies/tweak their exercise program to target impairments, etc. Much like what I see with patients who come to P.T. under direct access when intervention happens sooner or when the problem is less complex, I would expect you would see the person less often for bigger problems if you can educate/collaborate on a preventative basis.

I like the idea of having bi-annual or annual PT check-ups to discuss preventative care specific to their ADLs. I feel most discussion would be on work station ergonomics and preventing upper/lower crossed syndrome. Also, educating patient’s on postural awareness and the increased potential for injury with poor posture.

I think Myra’s comparison with dental checkups every 6 months is a good comparison. Just as they see less cavities with checkups. I think we would see a decrease in injuries and pain. Particularly shoulder, neck, back and knee pain based on the effects we know posture and mechanics have on these body regions.

With the talk of annual/bi-annual check ups, do you guys feel the FMS and SFMA screening tools would be beneficial to perform during these check ups?

One of the reasons I got into PT was the fact that we get more time than any other health profession talking to and getting to know our patients.

The article has a section called “a single medical encounter as the center of decision making”. They talk about all the other factors that go into a decision other than what happens during one doctor’s visit. People are constantly googling, youtubing, talking to friends and family, trying to decide between treatment options. I think the fact that we get so many encounters with the patient makes us the prime candidates to implement the model proposed in the article.

Encounter prep –> Encounter –> encounter processing –> feedback, continuation, resolution.

This takes into account that what people perceive or take away from our encounter may be radically different from what we were intending to communicate!

Also, I like the fact that they discuss that this may lead to fewer numbers of visits, because, similar to Myra, I have seen patients benefit from this type of wellness model. A patient with a nagging ankle pain that is not serious enough for them to seek treatment may benefit from a one-off consultation for them to work on the issue at home.

If you see that person back in 1 year/6 months and the issue is no better or even slightly worse, I think this is the appropriate time to initiate further interventions/education/PT which can lead to a resolution of symptoms prior to them becoming catastrophic.

Justin, I think I like the standardized process and scoring that the FMS and SFMA provide, as it would help as quick frame of reference for how the person is changing from check up to check up. I think if this model is where our profession goes then we will get more and more whole body screening metrics that are produced by private companies and by research groups. Is anyone familiar with any other standardized tests similar to the FMS? Scott I know you perform comprehensive screening somewhat regularly in your clinic, what sort of standardized method are you typically using?

My only concern with using something like the FMS/SFMA in our checkups would be that it might be easy to fall back on such an assessment as the primary driver of exercise prescription versus using our clinical reasoning. I think I am wary of anything that looks to assign a certain set of exercises to a particular measured deficiency. To be honest I am not very familiar with either screening tool so someone else chime in to correct me. I realize it is meant to be a screening tool but would not want its regular use to take a large role in our evaluation and treatment of patients.

Good point Scott. I have had several patients I have discharged with still some a few functional limitations. When discussing discharge with them, the conclusion was made that they could manage their symptoms on their own for awhile based on the treatment strategies I had given them. This is definitely the patient you are referring too. It would be great to see this patient back in the clinic in 6 months to see where they stand with their ADL function in regards to their pain.

August, I also have no experience with functional screening tools but was curious as to everyones thoughts on implementing these as a screening tool. I agree that only using a functional movement screen could limit our clinical reasoning and judgement like you mentioned.

Gus, I haven’t used FMS or SFMA specifically, but I’m somewhat familiar with them.

In our wellness type visits they usually start with an in depth discussion of the person’s responsibilities and activity level, previous injury history, and any current complaints of pain ( 10- 15 minutes )

Quick walking gait assessment, followed by quick running gait assessment if that person is a runner. ( 2 minutes)

Balance screen (30 second- 1 minute)

Functional squat assessment ( 20-30 seconds)

AROM and OP for cervical, shoulder, elbow, hand. AROM and OP for lumbar, hip, knee, ankle. (10-15 minutes)

Selected muscle testing/ further testing based on clinical reasoning (5 minutes focusing on problem area)

Home program prescription – 10 minutes

And that’s a 60 minute wellness eval!