Having trouble talking to your patients?
Two articles published over the last two weeks suggest that we might be having some problems talking to our patients.
The first, by Sullivan, Hebron and Vuoskoski (Sullivan, Hebron, & Vuoskoski, 2019) looks at the anxiety experienced by physiotherapists ‘selling’ their own explanations of chronic pain to patients. The therapists were trying to be patient-centred, but their efforts were undermined by ‘an underlying paternalistic wish to get patients “on board”’ (ibid). The authors attribute this anxiety to the confidence that the therapists feel in their biomedical understanding for pain, coming up against the patient’s values and beliefs that either contradict or destabilise their confidence and offer a more personally meaningful counter-narrative. This is a finding that has been echoed many times before in healthcare research, and lies at the heart of many patients’ complaints about not being believed (Dierckx, Deveugele, Roosen, & Devisch, 2013; Bourke, 2014).
Coincidentally, the study by Cupit, Rankin, Armstrong and Martin (Cupit, Rankin, Armstrong, & Martin, 2019) published this week in Sociology of Health and Illness, found nurses, GPs and healthcare assistants (HCPs) so dominated by the rhetoric of evidence-based medicine that they were unable to ’meaningfully ‘involve’ the patient and to support behavioural change’ (ibid). Rather than their discussion of the risks of cardiovascular disease being a collaborative process in which ‘patient and HCP work together to identify the best course of action for the individual patient, the ‘discussion’ has become a transaction’ (ibid), that offers ‘little to help patients manage the uncertainties and problems thrown up by the risk score’. The HCP’s main concern was to draw their patient into ‘actively ‘choosing’ the institutionally sanctioned course of action (seemingly overruling patients’ queries and uncertainties)’ whilst simultaneously using language ‘such as ‘patient‐led’, ‘communication’, ‘involvement’ and ‘shared‐decisions’, thereby constructing a belief that they were enacting these patient‐focused values’ (ibid).
The Sullivan paper is particularly telling because it argues that physiotherapists feel unprepared for the kind of uncertainties they experience when their officially-sanctioned beliefs are not shared by the patient. This is perhaps not surprising, though, given the weight of emphasis placed on the acquisition of confident, assured, objective knowledge of the body in health and illness in physiotherapy training, and the lack of structured and thoughtful approaches to the uncertainty and ambiguity that is the hallmark of real healthcare.
The recent exhaustive review of the physical therapy education system in the United States conducted by Gail Jensen and colleagues (Jensen, Mostrom, Hack, Nordstrom, & Gwyer, 2019) has highlighted the need for much greater attention to the humanities. Whilst celebrating some fabulous examples of clinical education, there is a sense that some therapists learn the humility and reciprocity of shared decision-making despite rather than because of their training. This is a worrying sign if health professions learn that gold-standard, evidence-based healthcare is something to be imposed rather than being a starting point for a conversation in which the power of the client/patient is never less than equal to the specialised knowledge of the therapist.
Reference
Sullivan, N., Hebron, C., & Vuoskoski, P. (2019). “Selling” chronic pain: physiotherapists’ lived experiences of communicating the diagnosis of chronic nonspecific lower back pain to their patients. Physiother Theory Pract, 1-20. doi:10.1080/09593985.2019.1672227
Bourke, J. (2014). The story of pain: From prayer to painkillers. Oxford: Oxford University Press.
Cupit, C., Rankin, J., Armstrong, N., & Martin, G. P. (2019). Overruling uncertainty about preventative medications: the social organisation of healthcare professionals’ knowledge and practices. Sociol Health Illn. doi:10.1111/1467-9566.12998
Dierckx, K., Deveugele, M., Roosen, P., & Devisch, I. (2013). Implementation of shared decision making in physical therapy: observed level of involvement and patient preference. Phys Ther, 93(10), 1321-1330. doi:10.2522/ptj.20120286
Jensen, G. M., Mostrom, E., Hack, L. M., Nordstrom, T. M., & Gwyer, J. (2019). Educating physical therapists. Thorofare, NJ: Slack Inc.
Sullivan, N., Hebron, C., & Vuoskoski, P. (2019). “Selling” chronic pain: physiotherapists’ lived experiences of communicating the diagnosis of chronic nonspecific lower back pain to their patients. Physiother Theory Pract, 1-20. doi:10.1080/09593985.2019.1672227