The desperate patient – causes the desperate clinician- to do desperate things.

If there is any one word I find myself using on a regular basis in both these blog posts and when talking to my fellow clinicians it is the word self-efficacy. 

I think back to my early days working in private practice. A middle age gentlemen, couldn’t have been any older than 55, came in with a recurrence of his medial sided joint line tenderness of his left knee. His name was Paul. I was sat in my clinic room and when I heard the front door of the clinic open I heard a booming scottish accent bellow the words ‘right, which one of your physio’s is going to be zapping my knee today then?’ he said to the receptionist. 

I’d never met Paul before so I grabbed his previous clinic notes from past visits which resembled the entire works of JK Rowlings Harry Potter series.

They read as follows:

14/02/2015 1MHz 1:1 0.8 W/Cm2 and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

16/02/2015 1MHz 1:1 0.8 W/Cm2  and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

18/02/2015 1MHz 1:1 0.8 W/Cm2  and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

24/02/2015 1MHz 1:1 0.8 W/Cm2  and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

01/03/2015 1MHz 1:1 0.8 W/Cm2  and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

I decided to flick the pages back even further. 12/12/2011. 1MHz 1:1 0.8 W/Cm2 and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

Ok Let’s go back a bit more I thought! 06/08/2008. Aaahhh Here it was the first admission for left knee pain (lets ignore the rest of his problems for this blog). The notes read:

“Patient presented with left sided knee pain after going for a long walk with his dog 2 days ago. No Locking/No Clicking/No trauma/ No giving way. Positive medial joint line tenderness. Clinical Impression: Medial Meniscus Tear. ?Arthoscopy. Well That escalated quickly.

So up I get and walk through to the clinic reception, notes under arm, and before I even get chance to introduce myself Paul is thundering full steam ahead into the clinic room with a gait cycle resembling that of a wounded animal. Up he pops. Straight onto the plinth. Trousers round his ankles. 

“I’ve not seen you before son.” (just to clarify he is not my dad)

“Hello Paul, my name is Matt. I’m one of the physiotherapists here”. Would you mind telling me a little bit about why you’re here?”.

“Are you taking the piss son. It’s my bloody left knee. It’s knackered lad – now be a good lad and get that machine over there on it!” He barked back.

“Do you think before we do that maybe we could have a little chat about the issue to see how I can help you best?”

By now I could tell I was really saying all the wrong things. The look he had on his face was one of a man who knew his way round this clinic room and had seen his fair share of physios.

“I’ll tell you what – get that machine buzzing and we can chat as we go – how does that sound.” (It sounded bloody tragic but by now I could feel my face burning up and even a bead of sweat rolling down my arm pit)

“Sound’s good” I feebly responded with what felt like a frog stuck in my throat.

I wheeled the machine over looking at it the same way I did a washing machine in my first week of University – completely perplexed. 

I proceeded to analyse the machine with Paul watching over me like a hawk stalking it’s prey. To be fair by now Paul virtually had shares in this ultrasound machine, he should be self treating while I sit in the corner and supervise!

F*** sake how do I work this thing! I wondered in my mind! There it is! The ON switch!!! As the screen lit up it was go time.1MHz 1:1 0.8 W/Cm2 I repeated in my head over and over as I scrolled through the numbers using the dial on the machine. A quick squirt of the lubricating gel on the ultrasound head and we were ready. GAME TIME.

Hold on a second – I haven’t even examined the thing! What am I doing!

The desperate patient – causes the desperate clinician- to do desperate things.

As I put the ultrasound head onto his knee he looked at me like I had just cold called him asking about his mis-sold PPI.

“Wrong one son.”His intimidatingly deep voice boomed.S***

Take 2. I placed it onto his left knee – medial side and off we went!

“So what do you want to talk about- the weather, holidays, TV, Football?” – It was like a new man was on the plinth! His whole demeanour had changed, like a crack addict who had got their latest hit.

“Tell me about your knee, Paul”

“My Knee? It’s shot. Knackered. Bone on Bone. Its grinding together – I should never of gone for that bloody walk! Doctor say’s if I don’t get it seen to now by you good people then it will be a knee replacement next year but they probably won’t do it because I’m too young – so I’ve stopped bloody everything!”

“How was it before the walk?”

“Perfect- I’d never had a problem with it! After that walk it hurt to put weight on it for a couple of days so I came here and your colleague told me about the cartilage being worn away.”

“Ahhhh it’s feeling better already son!” Paul said.

“It’s had a big impact on your life then” I stated.

“Too right – no more taking the dog out, I’ve gained weight, I’m a diabetic now, and I can’t play football with my grandson! But I’ll tell you what, I’m not having one of those metal knees, I’ve seen a video of them things being done – brutal!”

We continued to chat in this way and by now you should be building up the picture. Acute episode of knee pain some years ago after having NO prior knee pain, comes to see his doctor and a physiotherapist. Given some crappy diagnosis and treatment with no reassurance and scare the living crap out of him and destroy his quality of life. And where is his self efficacy now? Well every time that ultrasound probe made contact with his skin I can assure you it was sucking the life out of it. Paul was a victim of the machines!

I glanced over to the ultrasound machine. S*** I never even started the thing!

“Much better now son- cheers for that! Same time next week then?” Paul said as he clocked the time and recognised the treatment should be reaching its conclusion by now.

Like hell was I going to just let him walk out of that room with a bit of lubricant on his knee making him feel better.

I proceeded to assess his knee, 125 degrees of flexion, minimal joint line tenderness, negative meniscal tests. What’s going on I pondered. This guy came into the clinic in agony and was leaving with a nice bit of placebo only to be heading through to reception to book his next treatment for the following week.

“See you next week Matt!” his strong Scottish accent echoing through the waiting area.

When my clinic ended that evening and I was sat writing up my days notes the clinic owner poked her head into my room.

“How did it go with Paul today Matt? Nice and easy, usual treatment?”

That stuck in my head and when Paul came back to see me the following week usual treatment was abandoned. This was my one of first realisations of how I could do more as a physiotherapist to help empower my patients!

Now this blog isn’t about how I treated Paul (although I will do one on request) but instead about how these machines and passive treatments rob our patients of their self efficacy.

But…..I use manual therapy and passive treatments to get a buy in from my patients – I hear clinicians cry. If that’s your response then I suggest you look a little deeper at your so called ‘soft skills’. When you hone your soft skills then the buy in comes naturally, without the need for all of these sham treatments.

A blog from Adam Meakins entitled Abandoning Manual Therapy summarises this perfectly in this one paragraph:

“In my opinion manual therapy is often used to justify the therapist’s existence giving them a feeling of purpose and responsibility, and often used to pander and pamper to patients rather than to genuinely help them.”

And would this even be a blog without some knowledge bombs from my idol, Louis Gifford.

Gifford points out that as a profession, we struggle to give our patients rational answers to simple questions and make clear what we can and cannot do. Think about it, what information do you expect to receive from the doctor when you have a bad cold? Do our patients really expect us to fix them or do they want the answers to these four simple questions…

  1. What is wrong with me?
  2. How long will it take?
  3. What can I (the patient) do for it?
  4. What can you (the healthcare provider) do for it?

By the way, the answer to all 4 of those questions is not an machine with some gel on it just like my good friend Paul now recognises.

As always people.

Stay Honest.

@Honest_Physio

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