“Far better is it for an army to be too savage, too cruel, too barbarous, than to possess too much sentimentality and human reasonableness.” – William James
Between various fields (and sub-fields) there are spats we have playfully coined as ‘turf-wars’. In my chosen field of physical therapy, our turf wars are with/against physicians, physiatrists, chiropractors, massage therapists, acupuncturists, homeopaths, naturopaths, etc. Of course, even where physical therapy has raised its flag in victory, there is disagreement among the ranks – there are those whose specialties are in bio-mechanics, others in motor control, another group in a neuro-centric approach…the list goes on, and on, and…
. . . .
Bea’s pain management specialist had referred her to home care physical therapy; I was handed the assignment of completing her agency admission visit. Bea had been in the MD office recently for low back pain with radiculopathy and trochanteric bursitis.
I called Bea at 08:15; she was pissed off. She shouted at me for calling her so early in the morning. “How dare you call an 85-year-old this early in the morning?!” she yelled. She instructed me to call her back after we hung up and leave my phone number on her machine; she would call me when she was ready to talk. 25 minutes later, I received a call from the pain management office: they notified me that Bea had been convinced to receive outpatient physical therapy and had called their office yesterday to cancel her home care visit.
At 10:50, Bea returned my call, angrily. I was informed (in no uncertain terms) that I am to NEVER call anyone her age so early in the morning, that I am to always talk slower and I sounded too young to be of any help to her. I apologized emphatically for waking her and expressed my regrets that I had woken her when she had no intentions of pursuing home care physical therapy anyway. Then she began to cry.
It turns out that she had (proactively, to her credit) called a local clinic to inquire as to what they might have to offer that home care could not. She was informed that there would be little that home care can offer her, because she has no significant equipment in the home and that she would be better off going to their clinic. This conversation prompted her to cancel the home care visit, but now she was confused, crying. She explained that her pain was too severe to tolerate a lot of time in the car. She had no ride to get to a therapy clinic; the one person who could drive her is out of town and Bea is now unable to leave her home for the next 9-10 days. She did not know what to do. She was overwhelmed.
“I just want to stop feeling this pain. It is killing me. I am at a loss. What can I do?”
We talked for 20 minutes. I informed her that even if she did go to a clinic, it sounded as though her condition would prevent her from using equipment right away, and that any therapist (in the home, or in the clinic) would need to begin her care very conservatively. I offered her an evaluation to determine if there was anything that home care physical therapy could offer. I assured her that she could cease the evaluation at any time and I would provide her with an honest assessment of her prognosis and we could collaborate to develop a plan of care after completing her evaluation. She would not be pressured to commit to any further visits.
After I hung up the phone, I called the referring physician’s office back – I needed verbal orders to complete the evaluation. I shared with the pain management nurse that the patient seemed ‘distraught’ over the phone, but that she had asked me to visit later in the afternoon.
“Yeah, that sounds like Bea. Have fun with her. She is a mess.”
I spent 3 hours with Bea yesterday. I completed enough paperwork to complete an admission, but could not check-off a single item on the PT evaluation, itself.
What was I doing? I listened about how her husband had recently passed away. I heard about how debilitated she is and how she can’t travel anymore. I heard about how she fell in September 2013, developed pain in her low back in October that spread to her entire right lower extremity by November. I listened as she told me about the hydrocodone, the gabapentin, and the lidocaine that she was prescribed by her primary-care physician, before being referred to the pain management clinic for injections and fentanyl patches in April this year. She told me about the hip pain that has worsened over the last 2 months and the unsuccessful cortisone injection 2 weeks ago. Meanwhile, Bea is trying desperately to make arrangements to keep her appointments at the pain management office for acupuncture and deep tissue massage.
It turns out that Bea is a proud retired entrepreneur who was strong enough to care for her husband for 15 years as he slowly declined with Alzheimers – but she wept uncontrollably 5 times while talking about her deceased husband, her pain and lack of sleep, her loss of independence, how powerless she feels, the financial toll from medications and medical services, how lonely she is, how she is helpless, feels that she will never feel well again and is too scared to move.
I went back today to try to teach her to move again, if only a little. We talked about needing to reintroduce movement a little bit at a time to reassure her nervous system that movement can be comfortable again. We talked about her brain/body being hyper-vigilant, protecting her unnecessarily and how slowly and carefully one might need to approach a frightened dog in a park. We made arrangements for her to receive a psychiatric consult to address her (likely) depression. We talked about remaining hopeful, but about establishing small, attainable goals. This weekend she is going to complete one simple ‘exercise’ (the only movement that wasn’t provocative during today’s assessment) and she is going to take a short walk every day with her walker to the mailbox.
Today, I convinced her to cancel the acupuncture and the massage therapy; her insurance pays for neither. I told her how difficult it can be to determine what is contributing to a patient’s improvements/worsening of symptoms when there are multiple therapies involved simultaneously. I told her that there is more evidence for the benefit of physical therapy for painful conditions. What I didn’t tell her was that the evidence is not overwhelmingly positive.
Nonetheless, I spent 2 days fighting a battle and I won. But I know that long after her care has concluded, memories of Bea will haunt me.
Her physician did not apply best practices when addressing the initial onset of symptoms. Her pain management office tries to address her pain as if it is simply a bottom-up process while calling her a ‘mess’ and convincing her to do ‘everything she can’ to get better including acupuncture and massage. Meanwhile, she is caught in the middle of a tug-of-war between physical therapists in home care and an outpatient clinic.
Perspective is everything. While my story is one of a turf war, Bea’s story is one of insurgency and terrorism. It is one where multiple parties are vying for the privilege of billing for a service rendered that (at best) may have a minimally positive impact on her painful complaints – if her outcome exceeds that, she becomes a statistical outlier. She has been bombarded with information, most of it inaccurate or incomplete. She is shell-shocked. She is traumatized. She is stuck in her home, scared to leave.
2 months from today – in all likelihood – she will be telling the same story to another clinician…only, this time, her story will be a little bit longer. Unfortunately, they won’t give her 3 hours to share her story and a simple questionnaire will not be able to capture all that she has been through.
If only it were safe for her to hide in her bunker; the turf war is far from over.