Learning From Experience, Pt. 7
1 of the major pitfalls of most PTs is failure to rigorously practice the exercises they prescribe to patients.
— Christopher Johnson (@chrisjohnsonPT) October 4, 2014
I read the above tweet when it was posted and nodded my head in agreement. 6 weeks later still, I was laying in bed ill and apathetic to my family, my patients, and myself. I just wanted to lay in bed. I didn’t want to move. I didn’t want to read. I didn’t want to write. It wasn’t that I didn’t care if I existed – I didn’t care how I existed…and this was Monday, less than 48 hours since the onset of my illness. I thought to myself:
That was Monday. Four days after beginning antibiotic treatment, I was just beginning to motivate myself to type some thoughts that I had jotted down 48 hours earlier on a grocery receipt. I had my first meal with the family only the night before. Considering how the immune system had rendered a typically motivated and devoted father/husband into a useless and listless blob, I have a new appreciation for my need to more strongly reconsider how I approach some of my patients following a hospital stay after illness.
Each therapist brings their own biases into the patient’s home. My biases include:
- many patients don’t want me there – they oblige my evaluation only because it was a condition of their discharge from the hospital
- patients often get better on their own
- to over-medicalize a patient’s condition removes their locus of control
- patients deserve respect and autonomy, not paternalism
- other therapists who don’t appreciate items 2-4 likely overburden patients and our medical system while “helping” their patients
In my estimation, one of the challenging aspects of determining “need” of skilled services is trying to guess (someone else would say “assess”, but they are full of shit) if the patient is likely to have a spontaneous recovery from the hospital stay or if they will require home care PT to return their baseline.
Of 35 therapists on my agency’s staff, my therapy utilization is the lowest (or so I have been told). Why? Fueled by my biases, I understand that patients who are already able to get around their home safely will move around more as they feel better, so they will get stronger, so they will move around more….well, you get the idea. Traditionally, I have felt comfortable evaluating such patients for safety and independence alone, discharging them the same date. Nursing is typically involved for about 3 weeks, and they know they can re-refer me at anytime if the patient isn’t progressing as expected. Management has informed me that most therapists work with similar patients for about 2 weeks (3-4 visits) to help them out along the way.
After this entire immune-response that I have experienced I am reconsidering my assessment of patients who aren’t quite back to full strength yet after just coming home from hospitalization. How would I best assess their motivation? Every patient SAYS they want to get better – I would say the same – but I would also be content to just lay in bed too.
So how does that change my assessment? What I will NOT do is begin to see people with greater frequency arbitrarily. That would be ridiculous. What I am going to try to do, instead, is plan to arrange for a phone call with the patient 3-4 days after their evaluation, then discharge (if still appropriate) after a follow-up ‘teleconference’ (No, I am not billing a visit). In spending 5 minutes of time on the phone with the patient, we can discuss the findings of their initial visit and compare them to the abilities at the time of the call. Maybe I guessed wrong and their recovery is not as “spontaneous” as I would have otherwise anticipated, maybe not. Either way, it provides me with another opportunity to get things right.