Whilst on my neurology placement, I was required to attend multidisciplinary team meetings once a week. Those present at these meetings included the consultants, the registrar, the resident, the speech pathologist, occupational therapists, physiotherapists and the liaison nurse. Each patient on the ward was discussed in detail and all staff members were asked for their discipline specific input. I was required to present the physiotherapist point of view on the patients I had been seeing from my second week of placement onwards. To a student with limited experience in the field of neurology, this can be a daunting task when surrounded by very experienced professionals. I must admit that I was quite nervous sitting there waiting for the consultant in charge of your patient to say ‘Physiotherapy’ at which point your expected to provide valuable information to all those at the table about the patient’s condition.
Despite the initial fear, these meetings were incredibly valuable. It helped me to see how each of the different health professions use their individual specialties to work together to ensure the best outcome for the patient. It also made me think about the real practical value of physiotherapy in these patients. Does physiotherapy have an impact on the other health professionals treating the patient? The answer is a resounding yes, sometimes the physiotherapist ensuring that the patient is safe to walk outside is all the consultant needs to be able to discharge them, other times the physio working hard to get the patient to be able to transfer with one person assist is invaluable to the nursing staff. The thing I also found enlightening from these meetings is how much our opinion as physiotherapists and as health professionals is important to the consultants and other medical staff treating the patient. The consultants really look to us and to the occupational therapists to understand what the patient’s functional status is, and as such make a decision about the discharge plan for the patient. These meetings are also important in the sense that the allied health professionals see the patients every day of the week, whereas a consultant can not, there are times when the physio may notice a slight decrease in strength of a patient or the OT may notice a slight change in their cognitive function. This type of information may not be picked up by the medical staff but may be an indicator of a serious change in condition that needs further investigating.
These meetings helped me to understand that even though we may not have studied for as long or have the same rank as a consultant or those others around the table; our input is just as important to the patient outcome. If I was placed in the same situation again, I think I would approach it with more confidence and a personal sense of equality with those around me. By the end of my five weeks, I was actually enjoying these meetings; being able to make such an important contribution to the patient outcome gave the situation a whole new meaning.
Friday, May 30, 2008
Good communication vital prior to patient handling
During the first few weeks of my first placement, Musculo Outpatients, I was daunted by the amount of knowledge and manual handling skills required, as well as the variety of client presentations at the clinic. The musculo tutors always said that we had to be careful about being “too hands on”, and to make sure we always told the patient/client when we were going to be touching them so they didn’t get a shock as we suddenly had our hands on glut max or the ischial tuberosity. Supervising the clients exercise programs and prescribing new exercises was something that I found difficult, probably because rather than being “too hands on”, I was using a more hands-off approach. I felt like I was intruding on their personal space and that some of my clients, especially the older ones, would not appreciate me touching them in order to teach them an exercise. As a result I think that a few of my clients wouldn’t have had an effective HEP, since they wouldn’t have been doing their exercises properly.
I talked to my supervisor about this and she suggested that I talk to my clients about the necessity of touching them in order to teach them an exercise effectively; she told me that I should say something along the lines of “I’m going to place my hands on the muscles that move your shoulder-blade so that I can make sure that the right muscles are working”. By explaining exactly why I was touching the client and how that would help improve the way they were doing their exercises, I made both the client and myself more comfortable.
There are so many physiotherapy techniques that require us to touch our patients/ be “hands on”, and virtually every patient/client will need to disrobe to some degree. A lot of people are uncomfortable with this, especially the older population-which is an increasing percentage of our clients, so it is vital that we are able to properly explain to them why we are asking them to disrobe, and why we need to be in contact with them. This is another reason why it is so important that we build good rapport with our patients. As long as we are professional and communicate effectively, showing care and understanding for our patients, we will make our patients more comfortable, and we will be able to provide more effective treatment.
I talked to my supervisor about this and she suggested that I talk to my clients about the necessity of touching them in order to teach them an exercise effectively; she told me that I should say something along the lines of “I’m going to place my hands on the muscles that move your shoulder-blade so that I can make sure that the right muscles are working”. By explaining exactly why I was touching the client and how that would help improve the way they were doing their exercises, I made both the client and myself more comfortable.
There are so many physiotherapy techniques that require us to touch our patients/ be “hands on”, and virtually every patient/client will need to disrobe to some degree. A lot of people are uncomfortable with this, especially the older population-which is an increasing percentage of our clients, so it is vital that we are able to properly explain to them why we are asking them to disrobe, and why we need to be in contact with them. This is another reason why it is so important that we build good rapport with our patients. As long as we are professional and communicate effectively, showing care and understanding for our patients, we will make our patients more comfortable, and we will be able to provide more effective treatment.
Thursday, May 29, 2008
Clinical Expectations of Students
What is expected of me? A popular discussion topic amongst students, particulary those heading into their 3rd or 4th week of placement and still not really too sure what is expected of them. This is often with regard to students assessments, and the skills standards and autonomy of the student that are required.
The topic of conversation then drifts toward 'how do I bring this topic up with my supervisor, and what do I really want to say to them?' (a much better option than burying heads in the sand). I have listened to several fellow students discuss this amongst our peer group, with some very helpful suggestions and reasonings made. I later asked a few of people how their discussion with their supervisor went, and all reported that they had had a productive conversation. In these instances in was just a case of miscommunication, and the supervisor was only too happy to discuss the (minor) issues at hand with the student.
But what about the other end of the scale? What if your first couple of days at the placement are focussed around how you are going to be assessed? What happened to the clinical eposure and learning opportunities? By all means, it is fantastic that the clinical expectations of you are clearly outlined from the start and you are invited to ask questions... but there is a line. I have no doubt that supervisor I am referring to has all the best intentions, and aims to assist the student to make the most out of their placement at that facility, but thought that this was an interesting situation and gave it some thought.
Perhaps the difference is on a personal level. I hold the viewpoint that clinical placements are a wonderful opportunity to place what we have learnt over the past 3 years into practice, and for our supervisors to give us tips, suggestions and corrections along the way. Show us something new or different that they feel works well for a particular patient group. It is a little disheartening when your placement starts shaping up to be a giant OSPE, where we only go over what I have learnt in 2nd & 3rd year and are assessed as such. A very 'text-book style' approach.
We did discuss my eagerness do discuss/debate clinical reasoning decisions made during treatment sessions (rather than if I am going to pass or fail at this point in time). I emphasised that I was not challenging my supervisors clinical reasoning skills (they are the clinician with a wealth of knowlege, and I am a meager student) but rather wanting to discuss the treatment options so that I could develop an greater understanding and improve my clinical reasoning skills. They identified that as a person who trained in a different cultural context, their understanding and viewponts of student-supervisor relationships may differ from mine.
I believe we have come to understand that we have different approaches to certain situations, have recognised this, and I am looking forwad to learning as much from them as possible over the next few weeks.
And as for the ongoing emphasis on my final assessment... for the time being I will continue to smile and nod - it is a fairly trivial topic afterall.
The topic of conversation then drifts toward 'how do I bring this topic up with my supervisor, and what do I really want to say to them?' (a much better option than burying heads in the sand). I have listened to several fellow students discuss this amongst our peer group, with some very helpful suggestions and reasonings made. I later asked a few of people how their discussion with their supervisor went, and all reported that they had had a productive conversation. In these instances in was just a case of miscommunication, and the supervisor was only too happy to discuss the (minor) issues at hand with the student.
But what about the other end of the scale? What if your first couple of days at the placement are focussed around how you are going to be assessed? What happened to the clinical eposure and learning opportunities? By all means, it is fantastic that the clinical expectations of you are clearly outlined from the start and you are invited to ask questions... but there is a line. I have no doubt that supervisor I am referring to has all the best intentions, and aims to assist the student to make the most out of their placement at that facility, but thought that this was an interesting situation and gave it some thought.
Perhaps the difference is on a personal level. I hold the viewpoint that clinical placements are a wonderful opportunity to place what we have learnt over the past 3 years into practice, and for our supervisors to give us tips, suggestions and corrections along the way. Show us something new or different that they feel works well for a particular patient group. It is a little disheartening when your placement starts shaping up to be a giant OSPE, where we only go over what I have learnt in 2nd & 3rd year and are assessed as such. A very 'text-book style' approach.
We did discuss my eagerness do discuss/debate clinical reasoning decisions made during treatment sessions (rather than if I am going to pass or fail at this point in time). I emphasised that I was not challenging my supervisors clinical reasoning skills (they are the clinician with a wealth of knowlege, and I am a meager student) but rather wanting to discuss the treatment options so that I could develop an greater understanding and improve my clinical reasoning skills. They identified that as a person who trained in a different cultural context, their understanding and viewponts of student-supervisor relationships may differ from mine.
I believe we have come to understand that we have different approaches to certain situations, have recognised this, and I am looking forwad to learning as much from them as possible over the next few weeks.
And as for the ongoing emphasis on my final assessment... for the time being I will continue to smile and nod - it is a fairly trivial topic afterall.
Monday, May 26, 2008
Mild, Moderate or Severe?
Hi guys, hope everyone’s placements are going well.
I did my second placement in musculoskeletal outpatients. Of all the areas in physiotherapy, musculoskeletal is the one I find most interesting, and at the moment is the area I would like to work in once graduated. It seems that the general consensus amongst the fourth years is that the musculoskeletal practical is the most daunting due to the large amount of knowledge required, and hence the large amount of study prior (+++).
I was lucky enough to have musculoskeletal as my three week practical in third year and as a result had less difficulty than those who were being exposed to it for the first time. However, I did find I had some difficulty when it came to PPIVMS and PAIVMS. You may recall (or not?) from Musculoskeletal Science 351 that when it came to recording the findings of your PPIVMS and PAIVMS assessment that we were taught to record it as normal, hypomobile or hypermobile. At the Curtin Clinic on campus, stiffness (hypomobility) at a segment is graded and recorded as mild, moderate or severe (denoted by one, two or three horizontal lines). I personally liked this method of recording as it can help guide your treatment in those who have widespread stiffness by allowing you to select one or two segments that may be stiffer than the rest. However, I was continually finding that whenever my supervisor checked my PPIVMS and PAIVMS, her opinion of the grade of stiffness was different to mine. Because of this I found myself re-assessing each segment numerous times in order to get my grading correct, and probably seemed incompetent and lacking confidence to the patient in the process. I became disheartened (sniff sniff) by this until another student pointed out to me that the grading was subjective, and even if you were to have 100 physiotherapists assess the same person, while the general findings may be the same, their opinions of the grade may vary. From that point on I was much more confident in my assessment of PPIVMS and PAIVMS, and my assessment was much more efficient.
So for those who are currently on their musculoskeletal placement, or those who have theirs next semester and are asked to record in the same way, it may help to bear in mind that the grading is subjective, so don’t get too caught up in this! It is more important that you are able to recognise normal vs. hypomobile vs. hypermobile. Generally, if a segment/s is stiffer than others it is obvious.
Have a good week…
Tea or coffee... to drink or not to drink?
I am currently on a RITH placement (rehab in the home). Given the nature of this type of service, a lot of the patients tend to be quite elderly, and often living on their own. As a result, they are commonly quite lonely and starved of good conversation!
Whilst building up a good rapport with the patient is very important, I am finding it difficult at times to maintain an appropriate balance between letting the patient converse socially with me and actually completing the treatment in the required time-frame.
One patient in particular loves to chat, but isn't so keen on doing her exercises... The patient has very reduced exercise tolerance and balance/mobility following a long hospitalisation after a car accident. Whilst subjectively examining her, asking a simple question like "Can you tell me how the accident occurred?" often leads to a very long-winded, detailed answer along the lines of "Well I was travelling down this street heading to my friend's new house at this exact address... or was it this address? Hmm no definitely this address, then I turned right onto this road and took the next left onto this road, and because the time was exactly 5:46pm, the sun was directly in my eyes, etc, etc" (you get the idea!). Time was quickly being eaten up by unnecessarily long answers and it was very hard to get a word in and interrupt the patient without coming across as being rude.
The patient, who was German, then offered us a tea or coffee and we had to decline as time was getting on and we had other patients to see. The patient seemed quite offended by our refusal, so we told her perhaps if there was time on our next visit... The next time we saw her she invited us in and told us to have a seat around the table and again offered us a tea or coffee- explaining that in her culture, that is just what they do- as a good host you always offer visitors a drink (and they always say yes!). We hadn't even begun her exercises yet so we politely declined and again, the patient seemed quite offended. In the end I confessed to her that I actually don't drink tea or coffee anyway- so she offered us a soft drink. Accepting was the only way we could get her to move on and start exercising!
I spoke to my supervisor about the scenario and she explained that such situations are very common. She suggested that in the future, if I suspect the patient might be a chatty one, to say something right at the beginning (before subjective questioning) like "I'm going to ask you a few questions about your accident/injury, etc- sometimes I will want very detailed answers but for some questions it is not as important to go into detail, so if I do have to interrupt at any stage because time is getting away from us, please do not think I am being rude". She also suggested that I let the patient know at the beginning that I do not have long, because I have to get to my other patients.
The next time I saw the patient I suggested we get straight into her exercises so that we had time at the end to have a drink. Once she had done all her exercises, and the patient asked (predictably) if I wanted a tea or coffee- I simply asked for a water, and got the patient to pour herself a cup of coffee so that I could simultaneously assess how well she was handling basic functional tasks at home.
Often patients do not realise how precious our time is and that we are there for physio, not for a social visit. The skill of EFFICIENTLY extracting the right amount of information from the patient is a difficult one, especially with geriatric patients. The key is to build appropriate rapport with the patient without letting yourself (or the patient) forget that you are there, more importantly, as a physiotherapist.
Whilst building up a good rapport with the patient is very important, I am finding it difficult at times to maintain an appropriate balance between letting the patient converse socially with me and actually completing the treatment in the required time-frame.
One patient in particular loves to chat, but isn't so keen on doing her exercises... The patient has very reduced exercise tolerance and balance/mobility following a long hospitalisation after a car accident. Whilst subjectively examining her, asking a simple question like "Can you tell me how the accident occurred?" often leads to a very long-winded, detailed answer along the lines of "Well I was travelling down this street heading to my friend's new house at this exact address... or was it this address? Hmm no definitely this address, then I turned right onto this road and took the next left onto this road, and because the time was exactly 5:46pm, the sun was directly in my eyes, etc, etc" (you get the idea!). Time was quickly being eaten up by unnecessarily long answers and it was very hard to get a word in and interrupt the patient without coming across as being rude.
The patient, who was German, then offered us a tea or coffee and we had to decline as time was getting on and we had other patients to see. The patient seemed quite offended by our refusal, so we told her perhaps if there was time on our next visit... The next time we saw her she invited us in and told us to have a seat around the table and again offered us a tea or coffee- explaining that in her culture, that is just what they do- as a good host you always offer visitors a drink (and they always say yes!). We hadn't even begun her exercises yet so we politely declined and again, the patient seemed quite offended. In the end I confessed to her that I actually don't drink tea or coffee anyway- so she offered us a soft drink. Accepting was the only way we could get her to move on and start exercising!
I spoke to my supervisor about the scenario and she explained that such situations are very common. She suggested that in the future, if I suspect the patient might be a chatty one, to say something right at the beginning (before subjective questioning) like "I'm going to ask you a few questions about your accident/injury, etc- sometimes I will want very detailed answers but for some questions it is not as important to go into detail, so if I do have to interrupt at any stage because time is getting away from us, please do not think I am being rude". She also suggested that I let the patient know at the beginning that I do not have long, because I have to get to my other patients.
The next time I saw the patient I suggested we get straight into her exercises so that we had time at the end to have a drink. Once she had done all her exercises, and the patient asked (predictably) if I wanted a tea or coffee- I simply asked for a water, and got the patient to pour herself a cup of coffee so that I could simultaneously assess how well she was handling basic functional tasks at home.
Often patients do not realise how precious our time is and that we are there for physio, not for a social visit. The skill of EFFICIENTLY extracting the right amount of information from the patient is a difficult one, especially with geriatric patients. The key is to build appropriate rapport with the patient without letting yourself (or the patient) forget that you are there, more importantly, as a physiotherapist.
Sunday, May 25, 2008
Dealing with inappropriate behaviour
Whilst on my previous placement, i was treating an elederly pt who had undergone a TKR, this pt was often difficult to deal with as he would sometimes make inappropriate sexual remarks towards me, and also had difficult daughters who when present at treatment sessions would encourage this behaviour and interfere with treatment sessions constantly. Where as a routine ortho pt would usually take 30mins max to treat this man would often take me well over an hour due to his various behaviours.
When the pt first made inappropriate remarks about me, i just laughed them off as i was a bit shocked, luckily my supervisor was with me and told the pt that making comments like that towards me was totally unacceptable. The comments frustrated me as i felt they showed a total lack of respect, and it made me uncomfortable when going to treat him thereafter, as i wasnt sure how he was behave.
I discussed my pt's behaviour with my supervisor and he told me if he kept it up, to just tell him i was there to do his Rx . get it done as quickly as possible and leave.
Luckily i didnt have to resort to this, instead when i went to see him i was wary of my own behaviour and made sure that I was strictly proffessional and kept him on track and did not leave much time for general conversation but focused purely on the exercises. Although the pt frustrated me and i didnt like treating him, i still hade to make sure i gave him optimal Rx and never let my feelings show. Thankfully he caught on pretty quickly that the things he had said in the first few sessions werent acceptable and he adjusted his behaviour and Rx sessions improved a great deal and in the end i didnt mind treating him
The situation has taught me that although we must always behave proffessionally, there are some things we dont have to put up with from patients, however the main thing is to not take their comments personally or let them upset you, see it as their problem not yours and just ignore them and get on with the job have a bit of laugh about their behaviour and dont let them ruin your day. If i was faced with this situation again i would deal with it similarly howver if the pt did not adjust their behaviour i woulud get someone to come into the room when i was treating them also.
When the pt first made inappropriate remarks about me, i just laughed them off as i was a bit shocked, luckily my supervisor was with me and told the pt that making comments like that towards me was totally unacceptable. The comments frustrated me as i felt they showed a total lack of respect, and it made me uncomfortable when going to treat him thereafter, as i wasnt sure how he was behave.
I discussed my pt's behaviour with my supervisor and he told me if he kept it up, to just tell him i was there to do his Rx . get it done as quickly as possible and leave.
Luckily i didnt have to resort to this, instead when i went to see him i was wary of my own behaviour and made sure that I was strictly proffessional and kept him on track and did not leave much time for general conversation but focused purely on the exercises. Although the pt frustrated me and i didnt like treating him, i still hade to make sure i gave him optimal Rx and never let my feelings show. Thankfully he caught on pretty quickly that the things he had said in the first few sessions werent acceptable and he adjusted his behaviour and Rx sessions improved a great deal and in the end i didnt mind treating him
The situation has taught me that although we must always behave proffessionally, there are some things we dont have to put up with from patients, however the main thing is to not take their comments personally or let them upset you, see it as their problem not yours and just ignore them and get on with the job have a bit of laugh about their behaviour and dont let them ruin your day. If i was faced with this situation again i would deal with it similarly howver if the pt did not adjust their behaviour i woulud get someone to come into the room when i was treating them also.
Patient's Refusing Treatment
When I was on my neuro placement, I was treating a patient with a left hemiplegia. This particular patient was occasionally difficult to cope with due to the personality changes that occurred following the stroke and was also unable to walk. I went around to the patient’s room to take her to the treatment gym. This particular day the patient was refusing to come to physiotherapy, stating that she wanted to stay in her room. I tried to reason with her and explain how physiotherapy would help her and when she was finished she could come back to her room. Failing this I went and informed my supervisor that the patient was refusing to come to physiotherapy. My supervisor explained to me that sometimes it’s better not to tell them that they are coming to physiotherapy but that you’re just taking them for a ‘wheel’. She came with me and just said to the patient that she was going for a ‘wheel’ and took her to the physiotherapy gym, the patient was relatively co-operative and received at least a half an hour of treatment.
When the patient initially refused to come to physio, I felt that I would be taking advantage of the patient by just taking her anyway, as she had no way to resist apart from verbally. In some ways I felt like what my supervisor did was the right thing to do, as this particular patient really needed physiotherapy and due to her stroke she had a lack of insight into her situation and on many occasions displayed irrational judgment. However at the same time, I think the patient has a right to choose. This situation really raises an ethical dilemma, when is a patient not well enough to make their own decisions and when should we respect the decisions they make?
I don’t think that there is a clear cut answer to this question. From this situation I’ve learnt that to truly make that decision in a case like this you need to know the patient well, and in this way it will give you an indication as to whether their decisions are based on sound judgment or not. My supervisor had been treating this patient long enough to know what to do, and also had enough experience treating patients with strokes to make that call. It’s hard to know what I would do if faced with the same situation as I feel it really depends on the particular patient you’re treating. If it was this exact same patient I think I would try to reason with them first and explain the repercussions of not having physio, if she still refused I would leave her alone for a little while and come back later and try again. However, if the patient still flatly refused treatment, I would respect that decision as long as I felt that they understood what I was saying. I do feel that it’s important to first of all reason with the patient as much as you can, give them the opportunity to make their own decision and not take advantage of their situation.
When the patient initially refused to come to physio, I felt that I would be taking advantage of the patient by just taking her anyway, as she had no way to resist apart from verbally. In some ways I felt like what my supervisor did was the right thing to do, as this particular patient really needed physiotherapy and due to her stroke she had a lack of insight into her situation and on many occasions displayed irrational judgment. However at the same time, I think the patient has a right to choose. This situation really raises an ethical dilemma, when is a patient not well enough to make their own decisions and when should we respect the decisions they make?
I don’t think that there is a clear cut answer to this question. From this situation I’ve learnt that to truly make that decision in a case like this you need to know the patient well, and in this way it will give you an indication as to whether their decisions are based on sound judgment or not. My supervisor had been treating this patient long enough to know what to do, and also had enough experience treating patients with strokes to make that call. It’s hard to know what I would do if faced with the same situation as I feel it really depends on the particular patient you’re treating. If it was this exact same patient I think I would try to reason with them first and explain the repercussions of not having physio, if she still refused I would leave her alone for a little while and come back later and try again. However, if the patient still flatly refused treatment, I would respect that decision as long as I felt that they understood what I was saying. I do feel that it’s important to first of all reason with the patient as much as you can, give them the opportunity to make their own decision and not take advantage of their situation.
Saturday, May 24, 2008
The Importance of Creativity
During my paediatrics placement I was confronted with the issue of creativity or my lack thereof. I quickly learnt that the exercises that we have spent 3 years learning eg. Strengthening gluteus medius through clam shells was not going to work for young children. I thought it would be the same as getting an adult to do the exercise but maybe just getting the child to play or read a book etc while doing the exercise, but it was not that simple. I was at a loss, I knew what needed to be strengthened and or stretched within the child to improve their function but I was unable to implement such exercises because they would run off or wriggle away and find something fun to do. I realised that children are unaware of the fact that by stretching this muscle or walking a certain way will help them in the long term.
I quickly learnt that I had to switch off my physio brain with the standard exercises and somehow make them into a fun enjoyable game. My exercises started off relatively unimaginative consisting of making a bridge for toy trucks to drive under for strengthening gluteals but then progressed and became more creative with lying in prone on a large quads wedge and flying with toy aeroplanes and helicopters to stretch hip flexors and strengthen back extensors.
I also learnt that once an exercise is created it can only be performed a few times before it becomes boring for the child and you have to think of new and alternate ways of doing the same exercise eg. Marching was one of the exercises I had chosen for a particular child, but this soon became boring and we started to pretend we were soldiers and were marching around the fort.
Reflecting back on this situation realising that I have now developed some sort of imagination and creativity will not only be impeccable on another paediatrics placement but will be helpful in work in any area of physiotherapy in the future. I have come to the realisation that if you make the exercises fun and enjoyable but still challenging people are more likely to adhere to and perform them and ultimately that an essential aspect of our role in rehabilitation as physios.
I quickly learnt that I had to switch off my physio brain with the standard exercises and somehow make them into a fun enjoyable game. My exercises started off relatively unimaginative consisting of making a bridge for toy trucks to drive under for strengthening gluteals but then progressed and became more creative with lying in prone on a large quads wedge and flying with toy aeroplanes and helicopters to stretch hip flexors and strengthen back extensors.
I also learnt that once an exercise is created it can only be performed a few times before it becomes boring for the child and you have to think of new and alternate ways of doing the same exercise eg. Marching was one of the exercises I had chosen for a particular child, but this soon became boring and we started to pretend we were soldiers and were marching around the fort.
Reflecting back on this situation realising that I have now developed some sort of imagination and creativity will not only be impeccable on another paediatrics placement but will be helpful in work in any area of physiotherapy in the future. I have come to the realisation that if you make the exercises fun and enjoyable but still challenging people are more likely to adhere to and perform them and ultimately that an essential aspect of our role in rehabilitation as physios.
Dealing with abusive behavior
I was in burns unit as my elective placement and I was treating a guy with bilateral leg burns due to explosion of the oven. Upon subjective and objective assessment, he has normal knees and ankles range and pain at the burn site has been well managed by pain medication. During the first week of his admission, he has been doing daily phyiso treatment with me or the other physio staff there in order to maintain normal ROM and muscle length and he has been cooperative, compliant and keen to the exercise program being given.
The weekend passed, and upon my return on Monday, and I saw this patient again. When I walked in his room (single bed room with air lock) and asked him to go to the gym for exercise, initially the patient refused the treatment because he said he has extreme pain, at that time I thought he just didn’t want to go because all burns patients will compliant of pain. Then I explained to him the importance of keep doing exercise and asked him go to the gym. Then he became angry and abusive and started swearing at me. I initially felt really shocked and frightened because I never deal with this kind of situation before, but I stay calmed and listened and did not take it personally. He started crying afterward so I comforted him and calmed him down and let him to express his frustration. At the end I reported this incident to my supervising physio and she agreed my reaction to this incident.
On my self reflection, I think I will handle this kind of situation better if it happens again. Firstly, I think I should liaise with the nursing staff to gather information about patients so that I will know how well they are before I see them. If I know the patient becomes abusive I will not see him alone but with another physio staff to ensure personal safety. Also active listening to the patient and notice the non-verbal language, I think that will give me an idea of the emotional status of the patient and prevent the patient from going into abusive stage. More importantly, this incident gave me a lesson that I should explain things more detail and discuss the goal with the patient so the patient will know the expectations as well as increasing their motivation for treatment.
The weekend passed, and upon my return on Monday, and I saw this patient again. When I walked in his room (single bed room with air lock) and asked him to go to the gym for exercise, initially the patient refused the treatment because he said he has extreme pain, at that time I thought he just didn’t want to go because all burns patients will compliant of pain. Then I explained to him the importance of keep doing exercise and asked him go to the gym. Then he became angry and abusive and started swearing at me. I initially felt really shocked and frightened because I never deal with this kind of situation before, but I stay calmed and listened and did not take it personally. He started crying afterward so I comforted him and calmed him down and let him to express his frustration. At the end I reported this incident to my supervising physio and she agreed my reaction to this incident.
On my self reflection, I think I will handle this kind of situation better if it happens again. Firstly, I think I should liaise with the nursing staff to gather information about patients so that I will know how well they are before I see them. If I know the patient becomes abusive I will not see him alone but with another physio staff to ensure personal safety. Also active listening to the patient and notice the non-verbal language, I think that will give me an idea of the emotional status of the patient and prevent the patient from going into abusive stage. More importantly, this incident gave me a lesson that I should explain things more detail and discuss the goal with the patient so the patient will know the expectations as well as increasing their motivation for treatment.
Friday, May 23, 2008
Dealing with difficult patients
During my last placement (Neuro OPD) I was treating a patient who had had a very large ® TACS, with considerable (L) sided neglect, perceptual problems and decreased awareness of her deficits. She was often late for the sessions, didn’t participate fully in the session-she usually tried to talk her way through the sessions, and didn’t seem to want to come at all. In fact she often remarked that “all you want to do is hurt me”. This was all quite hard to deal with and the sessions became a battle of wills between her and me, which was difficult as she was usually only there for half of the 1.5hrs. Due to her decreased awareness she also developed goals/aims for treatment that were completely unrealistic, i.e. playing tennis (she had no functional use of her (L) arm) and would get very depressed and upset with everyone when she could not achieve this.
I talked to my supervisor about how I could improve my communication and general approach to treating her and improve the effectiveness of her treatment. He told me that I had to remember her diagnosis i.e. she has decreased awareness, perceptual problems and underlying depression, so her behaviour is not her fault; and that I had to improve my communication with her during treatment-she needs to know what is going on. He also told me that I couldn’t take what she was saying personally, as it was not directed at me. So I talked with her about her goals, explained how much work would be required to achieve them and the amount of recovery realistically possible. I tried to be as honest and as gentle as I could be, which seemed to get through to her, and she was a bit more positive after that. I also tried to remain objective in the sessions-trying to include the maximum amount of effective treatment. This was made easier when I involved her in the session-i.e. explaining what I was doing and why I was doing it, and how it would help her achieve her goals.
It is sometimes hard to interact with patients who seem to have a bad attitude towards you or physiotherapy, but it is important that we don’t take everything personally and take into account any internal and external factors that may be influencing the patient’s behaviour. It is also important that we don’t let our annoyance or frustration with our patients negatively influence their treatment-we must remain objective and treat them as we would anyone else.
I talked to my supervisor about how I could improve my communication and general approach to treating her and improve the effectiveness of her treatment. He told me that I had to remember her diagnosis i.e. she has decreased awareness, perceptual problems and underlying depression, so her behaviour is not her fault; and that I had to improve my communication with her during treatment-she needs to know what is going on. He also told me that I couldn’t take what she was saying personally, as it was not directed at me. So I talked with her about her goals, explained how much work would be required to achieve them and the amount of recovery realistically possible. I tried to be as honest and as gentle as I could be, which seemed to get through to her, and she was a bit more positive after that. I also tried to remain objective in the sessions-trying to include the maximum amount of effective treatment. This was made easier when I involved her in the session-i.e. explaining what I was doing and why I was doing it, and how it would help her achieve her goals.
It is sometimes hard to interact with patients who seem to have a bad attitude towards you or physiotherapy, but it is important that we don’t take everything personally and take into account any internal and external factors that may be influencing the patient’s behaviour. It is also important that we don’t let our annoyance or frustration with our patients negatively influence their treatment-we must remain objective and treat them as we would anyone else.
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