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Short but sweet editorial from a few years ago in JOSPT.
Have a read – post some thoughts.
How can you specifically use this powerful tool to improve your patient care/outcomes.
One of my favorite reflection editorials.
Cheers – see ya’ll next weekend
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This realm of literature and clinical practice has been dominating my desktop for the past 2 years. I feel there is so much to the patient-therapist interaction that we can affect and I’ve been fumbling with strategies to enhance these things most effectively.
I think this article points out a lot of low hanging fruit that we can all incorporate into our practice regardless of the patient in front of us: being engaged in the interaction, problem framing, an overall positive attitude. These things are universal and can be part of every interaction.
This article does end on a note that I feel is a bit more nuanced than the above factors. The author mentions shaping patient beliefs through our interaction.
I have found that maximizing positive contextual factors in PT practice has been a challenging balancing act. We have to minimize threat and fear while still validating the patient’s experience of symptoms. We should be very careful delivering messages like “your image doesn’t tell us the whole picture,” or “We can try and manage these symptoms without resorting to surgery,” because sometimes these things, while potentially true, can come off as dismissive and really hurt our interactions.
In this thought I reflect on an article I read earlier this year (see below, it’s only about 3 pages too. For the “TLDR” just start on page 3). I believe that validating a patient’s experience and meeting them where they are can have a great effect on the patient’s perception of the individual, and PT as a whole. These “soft skills” really are the things that drive our clinical practice every day.
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Agreed- it is so much easier said than done to delicately balance validation and “damage control” based on already established views.
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Being a new clinician we aren’t always going to know the “best” thing to do and come to the same conclusions as a seasoned clinician, which can be unnerving and overwhelming at times. However, the evidence out there, including this article, that points to the power of a positive patient-therapist relationship and placebo is something we can use to our advantage in spite of our lack of experience. As Taylor mentioned, this article points out the importance of being fully engaged and positive throughout patient interactions. It might be easier said than done in some instances, but this is definitely a simple tool that I can use to help improve patient outcomes.
This also makes me think of the cliche quote of “fake it ’til you make it” and how this comes into play with the placebo effect. You can’t expect a patient to trust and believe in your abilities when you can’t confidently present what you know, your plan of care, etc. This highlights the importance of your verbal and non-verbal communication in the face of uncertainty. One of the studies the article referenced stated that “low or negative expectations before treatment affected outcomes 6 months after treatment.” 6 months. Our words, mannerisms, and presentation of information matters, and building up positive expectations for treatment is a big part patient care that can’t be overlooked.
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I was thinking about “fake it till you make it” too! I think we often know more than we give ourselves credit for, and being confident in that and showing positivity to our patients can go a long way.
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I really like this article for a variety of reasons. On one hand it’s comforting to know that even if we don’t have the most accurate manual therapy skills, the best exercise prescription, or the latest and greatest tools, we are still going to help our patients. It’s a little bit of the pat on the back, “it’s going to be okay” to clinicians – if we’re really trying and want to help our patients get better, we’re at least accomplishing something with just that. If we are confident in what we know, are kind and engaging with patients, and have a positive attitude then we will likely still have good outcomes. I agree with Taylor that the placebo effect is an area of low hanging fruit that we can be using as part of our best practices. I also like that the article talks about how much we convey with our non verbals – the way we dress, how organized we are, what the clinic looks like, and even the paperwork and waiting room. I definitely think the entire concept of verbal and non verbal placebo effects are an area of untapped potential.
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There were two quotes from the article that I enjoyed. The first, “Our profession is committed to the principles of evidence-based practice”. The second, “We should strive to discover the patient’s expectations and then deliver and exceed it.”
After reading this article I was left reflecting on a question asked by my CI, “How are you going to shape the patient’s experience?” At the time, I did not have a good answer to his question. However, the answer he was likely looking for stems from this paper. Treat the patient in a way that is consistent with their beliefs, while also focused on best practice.
Shaping the patient experience may not only regard coming down to the level of the patient. Sometimes we have to rise to the level of the patient. Taylor and I recently discussed a time where the patient was highly educated. This individual required a more robust explanation of what our hypothesis was regarding his signs and symptoms. If this patient was told, “You have some normal wear and tear” they may have left the clinic feeling dissatisfied and/or invalidated.
As clinicians, it is our responsibility to read our patients effectively and provide a sweet spot that includes evidence-based practice, and patient expectations. In doing this, hopefully, we can inherently minimize nocebo while maximizing placebo.
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I really like how this article highlighted the importance of the mindset of the patient in regard to the outcomes of treatment. I think it really hit home for me that our words, demeanor, body language, and environment in general contribute to our ability to achieve that patient “buy in” into our skillset and ability, which is a big piece of the rehab puzzle. The patient’s outlook on therapy/rehab strongly influences his or her outcomes, and if we can start to shape this as soon as they walk into the clinic in a positive way, it seems like we increase our chances of positive outcomes right off the bat. As a new clinician, I feel like this is something that we can bring to the table immediately, especially since we’re still developing our clinical reasoning skills and manual techniques. I really like what Steven said about shaping the patient’s experience, and I think that question is a great way to head into every encounter, just to keep yourself accountable to every individual patient and to keep the focus on them and achieving their goals.
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“Placebo and nocebo phenomena are influenced by practitioner behavior, which affects both patients’ and clinicians’ experiences. This occurs at the point when the clinician’s wish to do good meets the patient’s desire to be helped. This phenomenon, coupled with therapeutic interventions, is where the art and science of medicine work
together—a mixture of the practitioner framing a positive therapeutic experience
and the use of evidence-based interventions.”I have read and reread the quote above over and over and have come to the conclusion that placebo, in itself, is not the most powerful treatment tool we have but placebo coupled with evidence-based interventions is.
Throughout schooling, the importance of verbage and positive language was ingrained into our studies. In one of the pain TNE lectures we discussed SIMs (safety in me) and DIMs (danger in me) and were presented an article discussing the effects of communication skills with our patients (attached below). This article states that possible benefits of effective communication skills include improvements in outcomes, adherence, and accuracy in problem identification. I have found myself altering not only the way that I speak but also how my patient’s speak about their impairments or diagnoses. For example, I have plenty of patients with knee pain or post-op TKA or ACL that refer to the affected leg as “the bad leg” which I quickly correct them to call it their “right” or “left” knee. A simple change in wording de-threatens the language and may redirect their view on their impairments or diagnoses.
I believe that placebo can be a very beneficial tool but can also be be detrimental if used without clinical judgement. One example, which I have been struggling with in my clinic (I may be biased), is the use of modalities such as TENs with my patients in order to increase my billable units…I very rarely, if ever use TENs due to the fact that I do not want my patients to become dependent/reliant on the feeling or effect that TENs has, as it is not addressing the impairments and is a passive modality. While it may decrease their pain by blocking nociceptive pathways with the pain gate theory, it has no lasting effect (that I know of) but the dependency of having “the electric zapper” at the beginning of the session counteracts the idea of the patient becoming independent and self-reliant.
This article really hits home in the fact that it focuses on the biopsychosocial aspect of care and how we as clinicians need to focus on our patient’s needs and expectations, as noted in this quote “…we should strive to discover the patient’s expectation and then deliver and exceed it to the extent that it doesn’t cause more harm. If a patient’s expectation could cause harm (eg, an early magnetic resonance imaging scan the patient doesn’t need), the onus is then on each of us to reshape the patient’s beliefs to be consistent with best practice.
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