“Responding to the Reluctant Patient”

How do you respond to a patient that doesn’t want to participate in therapy?  This is a paper from the August 2016 PTJ, but I only read it just recently.  I had my current student read it, and would highly recommend anyone in the SNF/TCU or acute care (or even HH) read it.  It really opened my eyes to how better interact with the reluctant patient.

Delany C, Anderson L.  From Persuasion to Coercion: Responding to the Reluctant Patient in Rehabilitation.  Phys Ther (2016) 96 (8): 1234-1240.

If you are thinking of working in a SNF/TCU…

I’ve had some students recently ask me about searching for work in the TCU.  I love the TCU setting – the medical complexity, the rehabilitation for all different diagnoses (ortho, cardiopulm, neuro), getting people back home.  If you are looking at TCU’s, these are some of the things I’ve considered when looking for work:

  1. The Medicare rating – 4 and 5 stars is a good starting point; I’ve worked at a 3 and where I was at until July was a 1 for a while (upgraded to a 2 currently) and I would still willingly work there, so I wouldn’t automatically cross one off your list because of this. [edit 5/2: my Dad is now in a TCU in Tennessee – tough searching from a distance.  Consider looking at the ratings also for health inspections and for outcomes – the ones I looked at I’d rather have a higher outcomes rating than a health rating as it looked like the health ratings were issues with documentation, food temp, etc and tended to be isolated incidents vs percent of residents with pressure sores, not returning to prior functional level, etc).]
  2. In-house vs contract therapy:
    1. Productivity will probably differ; from my observation in-house productivity is relatively lower (see my blog post https://geriatricpt.wordpress.com/2016/01/28/thoughts-on-productivity/ ).   Find out what their productivity expectations are, and what they might have to help you achieve it.
    2. Employee satisfaction: I work at a place with low turn-over – we could get more pay elsewhere possibly, but at what cost?  What is employee satisfaction like? (ask current employees away from the interview time – if you know any prior grads at a TCU ask what they think of their company, or go to a PT Pub Night, or ask classmates what companies and locations they interned at and what they thought about the corporate culture).
  3. Will you be at one site, floating as needed between sites, or doing HH as needed?
  4. Get a sense of how important rehab is to the facility – if they put money into the rehab dept (as it is where a facility makes its money) it makes a real difference.  If the gym is in the basement with no windows and little equipment, it may be depressing to you and to the patients.
  5. What is the con-ed budget?  Companies may offer CEU’s through ACP (the modalities company) or Medbridge and have less of a discretionary con-ed budget.
  6. Mentoring – is there a PT you can turn to as a new grad if you have questions or need help?  Ideally an official mentor, but that doesn’t happen really in this setting (or rarely).
  7. Will you be all alone as a new grad?
  8. Will you be responsible for a PTA (or two???) as a new grad?
  9. What is the typical day like – treatment times, diagnoses generally seen, etc.
  10. How much is TCU vs LTC vs OP?  (I have been in a combined setting most of my career thus far).
  11. Holidays and weekend – how many do you have to work, or are you on call, etc?
  12. Dress code?
  13. Weekend pay differential if you are required to work weekends?
  14. Do they reimburse licensure? (pretty rare in TCU)
  15. What is the nursing: patient ratio (and the NAR: patient ratio)

Motivational Interviewing

I’m presenting a CEU with a colleague and the director of the residency program tomorrow on balance and falls.  Part of my portion is on adherence to fall risk recommendations – I can’t go in depth in this CEU as I have at other times (when the topic was specifically adherence), and it has been a while since I’ve really dug into the literature on adherence in general other than monitoring it via PubMed’s weekly update email.  One of the adherence models used is the Transtheoretical Model (stages of change), which uses Motivational Interviewing, or MI.  In refreshing my memory, I found two good videos on this that I’ll post here.  Watching them reminded me how I found the TTM and MI intriguing, and that I’d like to take a class on it to get better.

Motion Analysis Software

In the clinic I use my iPad and HudlTechnique (basic is free) for showing a patient what I’m noticing in their movement or for me to slow it down so i can see better.  I thought I would pass along a new one I just found that is Windows-based.  I haven’t played with it yet, but it looks like it would be a great resource so I’m passing it along –  Kinovea is open-source.

Compendium for teaching professional level PT content (neuro focus)

From an email I received earlier this month.  If you are an instructor this is a great resource for neuro-related coursework ideas.

*************************************************

The Academy of Neurologic Physical Therapy is pleased to announce the
release of the updated *“Compendium for Teaching Professional Level
Physical Therapy Content, v. 2016”*. This compendium is an update of the
previous compendium published in 2000 and edited by Margaret Schenkman PhD,
PT and Kathleen Gill-Body, MS, PT, NCS.

The purpose of the Compendium is to provide examples of high quality
teaching and learning strategies that have been developed and refined by
the contributors. Some activities include detailed patient cases and/or
grading rubrics, which can be difficult and time-consuming to write. These
will be useful for novice faculty who are seeking innovative ways to
deliver content. In addition, experienced educators will find new ideas
and alternative teaching strategies.

The compendium is online, and open access
http://www.neuropt.org/education/compendium. Activities may be searched by
elements of the patient management model, by pathology, or by type of
teaching activity. *Activities can be downloaded individually, and
educators may freely adapt or adopt the learning activities while providing
recognition to the Academy and the original authors*.

The Compendium co-chairs would like to recognize the hard work of authors,
editors, and Academy leaders in developing this resource. We hope you find
it useful in planning your curriculum!

*Jody Cormack, PT, DPT, MS Ed, NCS*
* Sue Perry, PT, DPT, MS*
Compendium v.2016 Co-chairs

I have a bias toward therapy

I’m on a flight to go visit my father in the hospital. He had significant SOB, had a TEE which showed significant mitral regurgitation. We’ve had end of life discussions so know his wishes, and he wanted to have a valve clipping done (given his age and PMH it was recommended he not have open heart surgery, and this was the other option given to him). This is a relatively new procedure and I do have some questions I want to ask (including why no palliative care consult yet, will this reduce readmissions, change mortality, it drastically improve quality of life, and what are the complication rates).
I personally am questioning how much impact will this procedure have on dad’s life – cost benefit or risk assessment I guess; given that I work with sick people, have read Being Mortal, and have seen sad cases, I’m a little hesitant about surgery for him. I don’t want to see my Dad suffer either way. How do surgeons decide when to counsel conservative management, something other than what they are trained to do? ( His previous cardiologist knew of this problem and had recommended managing symptoms, but my parents just moved last month and had to reestablish health care providers, so this is definitely a different take on the situation).

Better yet, do I do any better? As PT’s we hear and agree #getPTfirst or #choosePT – we know we can make a great impact on people’s function and quality of life We talk about avoiding surgery if you can and avoid opioids. I want to bring hope. I hate it when I have to admit that i can’t restore function, return the patient home, etc. Most of the time it is easy – yes or no. But in the gray area, how long do you spend working at it? The patient with a CVA. The patient who has poor motor planning that isn’t responding to everything you can think of to help with mobility. The patient with pain you can’t really touch no matter what you do. These are the things you want to know as a student, and even as a practitioner there are ones that stick in your mind – did I do everything? Would a bit more, or something different help? I want to give hope, and I hate it when I have to say I’ve done all i can and we need to stop. Even therapy can’t fix everything. To a man with a hammer everything looks like a nail – i have a bias toward therapy and I need be aware of that for the sake of my patients, their families, and even myself.

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Sometimes the best teachers are where you least expect

I am clinical faculty for a local PT program for their ICE (Integrated Clinical Education).  During the a student evaluation last month, one of my students recommended that I involve the patient during my instruction and education to students as she felt the patient (who is to be the center of what we do) is left out on the periphery.  Wow.  Best feedback I’ve received thus far.  I came up with an idea how to implement it for next year.

I’m also a CI this summer with a 2:1 model for first-year students.  As I was asking a student what he observed about a patient transfer, explaining what I saw, and working on ideas of what we could do, the patient said “hey, I’m right here – talk to me!”  Ouch.  So now I’m prefacing my interactions with students to the patient saying I’ll be talking PT jargon to the students, but they will be explaining it back to you in non-technical terms.  In doing this a) we are involving the patient (and they know what is going on) and b) the students get to practice patient-friendly language (if you ever get stuck try the rubber ducky idea).

I love being a physio and a teacher, and also a student.  While I do miss academia, you can learn anywhere if you are open to it, and bettering yourself and others in the process.