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During our first weekend together we discussed the importance of the subjective interview from not only the perspective of gathering valuable information from the patient but a chance to develop a rapport and enhance expectations. Much of our success with patients comes from how we do things and less about what we do.
Below is a list of several resources that address more of the art of physical therapy. Find a couple of resources that interest you and consider posting about… what you learned, what you might attempt to utilize during your patient encounters, what you might try and change about your current practice patterns, a patient encounter you were reminded of where knowing more about this could have changed the outcomes.If you need access to any of these resources let me know, I’d be happy to share. Some of these resources are in the resident module 1.
On Opening the Clinical Encounter: https://www.chrisworsfold.com/on-opening-the-clinical-encounter/
Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes: https://pubmed.ncbi.nlm.nih.gov/27133031/
“I need someone to keep an eye on me:” the power of attention in patient-practitioner interactions: https://www.tandfonline.com/doi/abs/10.3109/09638288.2015.1129443?journalCode=idre20
What influences patient-therapist interactions in musculoskeletal physical therapy? Qualitative systematic review and meta-synthesis: https://academic.oup.com/ptj/article/96/5/609/2686357?login=false
A review of the psychotherapeutic “common factors” model and its application in physical therapy: The need to consider general effects in physical therapy practice: https://pubmed.ncbi.nlm.nih.gov/21913950/
Evaluation is treatment for low back pain: https://pubmed.ncbi.nlm.nih.gov/32091317/
Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain:https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-018-1943-8
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Resources read: “On Opening the Clinical Encounter” by Chris Worsfold; “Enhance Placebo, Avoid Nocebo: How contextual factors affect physiotherapy outcomes” by Testa and Rossettini (2016); “What influences Patient-Therapist Interaction in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis” by Keeffe et al. (2016)
I really enjoyed reading the three resources above and they served as another reminder of why I love the profession of physical therapy. One of the many great pieces of advice I received from a mentor while in PT school was the importance of customer service as it relates to our patients. As I’ve transitioned from student to clinician, I’ve gained a much better appreciation of the influence our behavior and language can have on patient outcomes/expectations. The first resource I listed looked at the importance of this from the very beginning, and how the way we open a clinical encounter can set the stage for the reminder of the rehabilitation process. I enjoyed what the author had to say about the influence this can have on a patient and feel there were some specific aspects that I could apply to my own clinical practice. I personally tend to start an initial evaluation with “okay, looks like you’ve been dealing (X) pain, why don’t you tell me a little bit about what’s been going on from your perspective.” This typically gives the patient the opportunity to give me their whole story, however, one major component of this initial clinical encounter the article mentioned that I think I could improve upon is when I interrupt the patient. Certain patients will talk for the entire visit if you let them which you have to be careful with, but I personally think I could do a better job of just letting the patient tell the majority of their story before I interrupt to clarify information or ask follow-up questions.
The other two articles I read dove deeper into the specific factors and characteristics of a physical therapist that, when applied on a more consistent basis, positively or negatively impact a patient’s outcome. The first article discussed the individual therapist factors as well as patient factors that can contribute to a placebo or nocebo response. I think (and hope) there’s a part of all of us who decided to pursue a career in physical therapy that enjoys interacting and socializing with others. This article speaks to that and then some by listing out strategies we can use to improve our patient-therapist encounter that has been shown in the research to promote positive patient outcomes. There’s certainly a lot to say about the power of positive thinking, whether it be in our personal or professional lives, and I think these articles point out our role as a physical therapist in promoting positive thinking for better outcomes. As I read both articles, I reflected back on patient encounters that haven’t gone as well as I’d hope and how I could’ve made the situation better by implementing some of these strategies early on. Specifically, I think setting expectations for both the course of the initial evaluation and for the remainder of the overall rehabilitation is something that I could’ve used to improve how patients respond to the interventions I provide. I also feel that emphasizing the intent for shared-decision making with the entire course of treatment is something that could’ve improved these patient encounters and made the therapy sessions more enjoyable for everyone involved.
As a whole, I realize there is a plethora of emerging evidence that points out the importance of the psychosocial component with patient care and less towards the biomedical aspects. Combining both is obviously the most ideal approach to patient care and my hope is that with time and much more experience, my ability to positively influence patients through my language, actions, knowledge, and behavior will improve. -
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I remember talking about openers for evaluations during the course and having that stick out to me. This is something I have always thought about, wondering if I was starting off the conversation on the right foot. I feel like my go to now is “what brought you into the clinic” to try to keep it open ended and not close any doors to pertinent information or other areas of pain the patient may be experiencing based on the referral. In the article “On Opening the Clinical Encounter” by Chris Worsfold, he references John Launer’s book about trained mentors and coaches starting off the conversation with “what are you hoping to get out of our conversation today?”. This made me think back to one of my patients who I did the subjective and then asked him what his goals were. He straight up told me he had to do physical therapy in order to get MRI imaging and that’s why he was there. I think if I would have asked him that question from the start it could have changed our conversation. For example, asking him more about his thoughts on what he thought is contributing to his pain and providing education on the benefits that physical therapy could provide him to improve patient “buy-in”. Fortunately, I was able to spend more time with him during the second session to do that. I also like the use of “tell me your story” that Peter O’Sullivan uses and then sitting back and listening without typing. I think that’s something I struggle with sometimes since I’m worried that I’m not going to remember everything they said, especially if I don’t have time to type before the next patient and I have a busier day. This is something I want to improve on. I do feel like when I’m trying to type, I might miss something the patient says or verbiage that the patient uses that can be used as an educational opportunity. For example, during mentoring last week, I had an eval for a guy with R low back pain. He had gone to the ER for his back pain initially and had a whole bunch of tests done and was still really concerned about his back. I was focusing so hard on listening and trying to write down notes (and a little nervous cause mentoring) and didn’t pick up on some of the things he was saying which would have been a good educational opportunity. I saw him again this past week and he straight up asked us if he had a disease that was causing his back pain. For me this emphasizes the importance of just putting the computer down for a second and giving the patient your undivided attention to listen for those things and being able to address them and educate the patient.
This also relates to the four themes that were identified that patients and physical therapists perceived to influence patient-therapist interactions in the article by O’Keefe et al. The first two themes listed were “physical therapist and interpersonal communication skills” and “physical therapist practical skills” which involved listening and patient education. This really emphasizes the importance of the first session to build that connection and trust with the patient. AJ and I talked after the mentoring session last week about how the patient with R low back pain is likely hesitant to move because of his pain and the second session only confirmed his fears when he asked if he had a disease. Providing the patient the education day one could have given him the reassurance that he was likely looking for that he did not have a disease or something more serious going on, and that it’s okay to keep moving.
Lastly, Elizabeth Crepeau in her article from 2016 also speaks to this discussing the two important aspects of attention that are important for building a therapeutic alliance: “listening” and the “clinical gaze”. Can’t emphasize the importance of listening enough, not just during the evaluations but during the treatments as well. During the mentoring session this past week, AJ and I talked about asking about the subjective asterisks at the start of the treatment to assess for any changes or things that could be addressed in the current session. Sometimes it’s the little things that patients say that they don’t expect you to remember and I feel like that says a lot to the patient when they noticed that you remembered and were listening. And then use that information that they are giving you to make the session patient centered. Overall, these are all great articles and provided great insights on how to build the therapeutic alliance with the patient. Becoming a better listener is definitely one of my goals for the residency and as a clinician.
References:
1.Worsfold C. On opening the clinical encounter. Published March 13, 2019. Accessed October 13, 2022. https://www.chrisworsfold.com/on-opening-the-clinical-encounter/
2.O’Keeffe M, Cullinane P, Hurley J, et al. What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Physical Therapy. 2016;96(5):609-622. doi:10.2522/ptj.20150240
3.Crepeau EB. “I need someone to keep an eye on me:” the power of attention in patient-practitioner interactions. Disability and Rehabilitation. 2016;38(24):2419-2427. doi:10.3109/09638288.2015.1129443-
Hi Emily, I like your thoughts about openers and I am in the same boat about often wondering if I am starting the subjective interview on the right foot. I typically explain the concept of PT and then I think I fluctuate between using, “Your referral says that you’re here for ____. Is that correct?” which I typically use if I’m unsure if it is indeed correct and “Let’s talk about where you are having symptoms” with immediate referral to the body chart and going through that. This often guides the patient to talk about their symptoms before explaining the MOI and often lengthy backstory so that I can make initial hypotheses without the bias of their HPI/PMH. Of course this hypothesis may change as soon as they give me this information, but I feel like it’s helpful to have the body chart mapped out sometimes before the whole story. Have you tried this method?
After reading these articles, I was thinking of switching it up too. I’ve had similar situations to the first patient encounter you described and I’ve used the “what were you hoping to get out of today?” with pts responding with “idk” or “whatever you thinks best”. That being said, I definitely think the opener and what’s best is situational and one thing doesn’t work for each patient, but its hard to tell when you’ve only just met them.
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Hi Clare, I haven’t tried that method yet but I like that approach starting off with the location of symptoms. I think that’s a great way of starting, and maybe getting hands on to confirm location of symptoms before getting the whole story. That probably stands out to the people who have seen multiple doctors who never actually do that and just sit and talk with them for 5 minutes before referring them to someone else. I will definitely try that during my next evaluation.
I also agree that the opener can be situational. I think asking the pt first what brought them in or where they are having symptoms first, you can definitely get more of a read of the patient and then adjust or ask questions as needed.
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I read “On Opening the Clinical Encounter”, “Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes”, “I need someone to keep an eye on me:”, “Evaluation is treatment for low back pain” and “What influences patient-therapist interactions in musculoskeletal physical therapy? Qualitative systematic review and meta-synthesis”. All of these resources had similar features regarding patient interactions and what we can do as clinicians to facilitate the best outcomes for our patients starting at the initial evaluation. While reading these different articles, I found that I was deeply reflecting about my recent patient interactions.
“STOP TALKING”. If you look at my work computer you’ll find a sticky note at the bottom right corner below the keyboard that reads “Clare” (because all of our computers look the same and I can never find mine) and directly below that “stop talking” written in all caps. While reading these articles, but especially “I need someone to keep an eye on me” and “What influences patient-therapist interactions in musculoskeletal physical therapy?”, I was reminded of my sticky note and a recent interaction with a patient. I have established good rapport with this patient and we have had some very open, honest conversations. At her last visit, I had to leave the room for a moment and when I returned, she was giving me a look representative of a concerned/disappointed teacher. I gave her the band and explained the exercise anyway. She acknowledged what I said, but then immediately stated, “I saw your note that says “Clare, stop talking”. I laughed and explained that I wrote that because I found that I had been over-explaining things to patients and potentially was being confusing. This patient proceeded to counteract that thought and told me not to lessen my voice and that my detailed explanations were much appreciated and actually really helped her understand our treatment and goals. She ended the conversation with “don’t be too hard on yourself”. My patient’s words and these readings have caused me to rethink my poorly placed sticky note. Education is at the forefront of our jobs and sure, maybe I explain a lot, but based on these readings, it is clear that patients benefit from education about their condition, our intervention choices and attention to detail/feedback during exercises. It’s likely that I sometimes lack confidence, feel as though I blabber when educating patients and thus I thought my note would be the solution to help me re-center my thoughts and be more concise. Let’s just say this sticky notes has been folded over.
Another one of the common themes from these readings was the importance of being an active listener. I have often prided myself on being a good listener but as a new clinician I have noticed it is sometimes a challenge for me to be a great listener when I am also trying to document, clinically reason, and respond to the patient all at the same time. I find myself looking at my computer instead of the patient, and actively try to adjust this, but it’s been difficult as I am getting used to the documentation system. This also relates to the flow of the clinic. I can’t help but wonder if I’ll be able to give all my patients the appropriate amount of attention when I start to see multiple patients with overlapping treatment times. “I need someone to keep an eye on me” was a good narrative report sharing the importance of having a clinician observe the patient’s exercises and this having a large effect on the patient’s motivation, commitment, and understanding of their care. I know that once I start seeing more patients, this will be an obstacle I will have to overcome in order to determine the best way to care for each of my patients.
I enjoyed reading Testa’s study regarding placebo/nocebo as this concept is generally interesting to me. When talking about the strategies to enhance placebo, the concept of facial expressions caught my attention because I’ve only been a clinician in the time of COVID. I am generally someone with more of a flat affect, and sounding outgoing or excited about a patient’s progress has been something that I’ve learned to do. Especially in the era of face masks, I’ve found myself having to use a lot more movement of my head (nodding) or eyes (smiling big to cause creases) or even giving verbal “yeses or “uh huhs” as the pt is telling their story to let them know that I am still engaged and not checked out. If we ever transition out of masks, I know this will be another challenge as I’ve also been able to hide my facial expression in more difficult situations.
Overall, these articles facilitated reflection on my initial patient encounters in a new way. In the future, I may try starting evaluations with a different phrase, use different strategies to show the patient I’m actively listening during care and be more conscious of how I may be encouraging placebo or nocebo effects during care.
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Hi Clare, I really enjoyed reading your response to the discussion. I definitely agree with a lot of what you mentioned with active listening while documenting, the concern with overlapping treatments, and with fascial expressions. For documenting, I’m going to try just typing most things into one box so I’m not having to click around and then just typing keywords so that I’m able to have more eye contact with the patient and not looking down at my computer so much. AJ also talked to me about summarizing what the patient said during the subjective and saying it back to them at the end to confirm whether you heard them correctly or if you missed anything. This is one of my goals for the first quarter that I think will definitely help with improving on active listening during the first encounter.
I’m also concerned with the overlapping treatments, I won’t be able to have my eyes on the patient at all times especially when I’ll have to hand them off to the PTA for part of the treatment. This makes the time that we do have with our patient so much more important to continue to build on the therapeutic alliance with them. It will definitely be a test for sure once our schedules start to build up more.
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AJ,
Thanks for your questions. I think you bring up a great point of the importance on how to redirect effectively. I find this to sometimes be difficult if a patient begins discussing at length their situation to the point where they are providing information that isn’t helpful towards my understanding of their presentation. I certainly don’t want to seem rude by interrupting a patient in the middle of a sentence or appearing frustrated that they are talking so much. It is often these moments where I begin to sense that the patient is bringing up irrelevant information or if they begin repeating themselves that I attempt to step in and redirect the conversation. How I redirect differs depending on the individual in front of me, but I find myself often circling back to information they provided in the beginning of the subjective that could help me paint a better clinical picture of their presentation (e.g. MOI, PMHx, aggs/eases). Specifically, I try to summarize or repeat information they have given me as a way to further my understanding, but to also demonstrate active listening so that the patient understands I value what they are saying to me. I also make a big point to individualize my subjective examination by ending with a question about their specific goals and explaining to the patient my intent to help them reach those goals, which I feel makes a huge difference in their buy-in and feeling like their values and preferences are being considered. -
Emily,
Great post! I think your points on understanding patient perceptions day 1 is so important, yet often so difficult to do. Finding that balance between listening intently to the patient in front of us but also ensuring that we don’t forget anything or leave ourselves with a lot more work is definitely one of the hardest parts of this job in my opinion. Although it does leave me with extra work, I often don’t bring my computer into the initial evaluation with me and instead use pen and paper. I personally think this makes the patient feel like I am paying more attention and based on my terrible typing skills, I’m able to make fewer mistakes while writing. Although, this does leave me with having to document all that I wrote down later on, which can definitely be time consuming.
I really like the point you made about reassessing subjective *’s. I think this would definitely help the patient understand that you are listening intently and empathetically into subsequent visits. That’s something I could certainly work on myself, asking specific questions about their subjective symptoms that are most meaningful to the patient in follow-up visits. What specific questions do you find yourself most often asking about? Is it more related to their aggravating factors? Or are you inquiring about changes in irritability (time for pain to come on, go away), goals, etc?-
Hi Ian, thanks for the response! I’ve also thought about just writing things down on paper but I’m not sure what’s better my typing abilities or writing. I definitely should give that another try though and see what I think works best. I do like to write down my objective findings which is easier for me so maybe sticking to the paper will be better so I don’t have to switch back and forth.
In regards to the questions, I think it’s usually a bit of both, asking about an activity/something that they did previously that aggravated their pain to see if that changed and determine if that is something we need to assess/focus on for the session. I am trying to get in the habit of asking more about changes in irritability which can be a good indicator of how the patient is progressing. That is definitely another good subjective * to ask about.
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Clare,
Awesome post! I enjoyed reading about your patient interaction and reflection on these first few weeks of residency. I think your patient was right, that it’s easy to be hard on ourselves especially when we are so new to this profession and trying to be the best clinician possible. I can relate to sometimes feeling like I am overexplaining or speaking at nauseam to a patient about their presentation. I certainly think every patient is different in that some appreciate this and actually benefit from thorough education. However, I think for some patients they couldn’t care any less so I find it’s sometimes a skill to pick up on those social skills and know when to emphasize more education.
Similarly, after reading the article “I need someone to keep an eye on me” I find myself feeling like I need to be with my patient throughout their treatment sessions, which leaves me with a lot more documentation to do at the end of the day. This is a dilemma I’ve been trying to navigate since day 1 of residency. I think every patient is different and some definitely need more attention than others, but I’ve found myself starting to get more comfortable with leaving the patient to do their exercises alone as rapport is established and I’m confident they are performing them correctly. What kind of strategies have you seen other clinicians use to ensure they are not left with a ton of documentation at the end of the day? Do you think it’s possible to change a patient’s perspective on being left alone during treatment if we set expectations early on?
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