A Teaching Moment

Jake is in his second week of an eight-week physical therapy clinical affiliation, the first of four field-work assignments that he must complete to be eligible to graduate in 2015 with his clinical Doctorate in Physical Therapy. He has a Bachelor’s degree in Exercise Science and has worked for two years as a physical therapy aide in an outpatient physical therapy clinic near his home.

On Wednesday, Jake and I were to visit Ms. Oliver for the first time after she returned home from the hospital following a total knee arthroplasty. Jake has seen and worked with many patients after a total knee replacement in the outpatient setting, but never a patient only 5 days after surgery. I spent a few minutes prior to the visit explaining to him what we should expect: with every visit we would assess Ms. Oliver’s risk of infection and DVT while monitoring her vital signs. We could expect her experience to include severe pain and guarding, edema, reduced range of motion, apparent weakness and difficulty with most mobility tasks.

To my surprise, Ms. Oliver was feeling and moving better than any patient that I have worked with so soon after a knee replacement. She denied any pain. Her edema was minimal. She already had full range of motion into extension and 95 degrees of flexion. She was independent with bed mobilty; she could complete a straight leg raise in supine without extensor lag and hip abduction was strong as well. She will receive only 2 more visits in the home care environment before transitioning to an outpatient facility next week.

After the visit was completed, Jake and I returned to the car. “So,” I asked Jake along the way, “do you think she is tough or lucky?” Jake looked at me puzzled before we stepped into the car, “What do you mean?”

As we closed our doors, I continued, “When we walked into her home we were expecting her to have a lot of pain, limited motion and significant strength deficits. Instead we saw someone 3 standard deviations from the mean. Ms. Oliver is the rare patient that feels and moves so well. In my anecdotal experience, maybe only 2 in 100 people are doing so well so soon after surgery. My question to you is this: Do you think Ms. Oliver is doing so well because she is tough or because she is lucky?”

Jake did not have to think long before he replied, “She is really lucky.”

“Exactly.” I responded. “Your responsibility from this point forward is to always remember Ms. Oliver, because at some point in your career you will meet someone who is doing as poorly after surgery as she is doing well. That future patient will be among the 2% percent of patients that struggle so severely with pain and poor mobility that their symptoms after surgery will be debilitating. They are the same patient that most therapists look at and call “a wimp” or “a pussy”. Other therapists will accuse the patient of not working hard or often enough.’

“Yeah,” he said, “I have definitely heard that before.”

“Thankfully for your patient,” I concluded,” you will know better. You will understand and remember how lucky Ms. Oliver was and how unlucky your struggling patient is. Your patient will be thankful for your service when such a perspective guides and informs your care.”

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2 thoughts on “A Teaching Moment

  1. Keith, Great, of course. And your student is a lucky one as well. But I can’t help but consider the flapping of a butterflies wings.

    • The idea of “flaping” is bouncing around my head as well, but with a different context…I will see if it manifests itself into anything useful.

      Thanks for reading!

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