The Self-Discharge Problem: Why I Lie to my PTs

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Today’s article is a guest post from Heather Chavin with CareConnections Outcomes Platform.


Physical therapists have two superpowers that help with healing, their hard-earned skills and education and their influential relationship with the patient. I believe there is a bias in the industry for the first. After all, you’re $200k in debt for the first and have almost no formal training in the second.

I believe this bias exists because I am regularly in clinics, talking to the staff and practitioners and reading their self-discharge reports. I also believe the bias exists because I am a patient. I have been to see four of the best PTs in the Pacific Northwest (maybe the country) in the past two years. I have been struggling with what I think is chronic high hamstring tendinitis or something like that.

The first discharged me after four visits because he had a model in his mind about how fast he got people better (side note: never discharge someone right after you’ve adjusted their coccyx – I don’t care how loud I yelled, that’s just rude). Then I self-discharged from the next therapist because this person wanted to do it right, but I was paying $150 cash out of pocket per visit and ran out of money. The third, I self-discharged because they got stumped and started recommending more imaging and possibly surgery.

The fourth therapist I’m still with, but I had to ask the PTA what my diagnosis was at a random visit (I felt like an idiot having to ask btw – not how you want a paying customer to feel). I learned more about my anatomy drunk at some hot springs talking to a PT friend who had an anatomy app on her phone. I struggle with my home exercise program because I can run with friends or go to a yoga class but doing exercises every day in my living room alone – not likely.

No one asked me if my HEP was realistic. No one asked me when I would do it and how I would track it and who would support me in trying to implement a new habit. Sometimes they ask if I’ve been doing it, sometimes not. I get a very skilled strength test from time to time so that says something. But I swear I passed the last strength test fueled by panicked shame for not doing my exercises consistently.

The common theme from one skilled therapist to another is it was all about THEIR SKILLS. At no point was it about ME. If I’m the one who needs to take control of my health and well-being, then it needs to be about ME. Otherwise you need to come into my living room every morning and be sure my exercises are getting done!

Don’t get me wrong. I’m 100% pro-PT. Each therapist has taken me a step forward, not a step back. Because I genuinely like and respect each of them, I buckle under the pressure of being honest with them about my lack of progress. 100% my cowardice, my bad. There’s no doubt about my therapists’ deep commitment to what they do and that they care. There’s just an unconscious orientation towards their skill set over my movement towards self-empowerment and new habit formation.

What’s happening here?

 

A Therapist-Centered Culture: Hey Fish, Did You Notice the Water You’re Swimming in?

Let’s take a step back and talk for a minute about culture. We like to think we operate from our values but our cultural context has a huge influence. Let’s look at an example.

I am part of a running group that has sister organizations around the world. You can find them on the internet and pop in for a drink and a run (and another drink) if you’re in town on the right day.

I ran with my local Eugene group regularly and occasionally would drive one town over to Cottage Grove and run with our neighbors. These two groups had wildly different cultures. Cottage Grove prioritized punctuality and adherence to rules and Eugene prioritized inclusivity and relationships. Neither would state this explicitly. I just gathered this information implicitly. Here’s how:

Cottage Grove

If you did not show up on time you could run but you had to wear a Cone of Shame. That’s one of those dog collars you use for keeping your dog from licking itself. After each run, this running group went through a process where you call out your peers for various crimes on trail and honors. In Cottage Grove, if you had a side conversation, you were called out to put your rear on a block of ice. The reward/punishment is always a song and a drink of beer. In Cottage Grove, if the leader pointed at you and you didn’t come up with a song, you had to either sit on the ice or drink a beer (or both).

So now you can see that no one says, “We’re all about rules.” They just put you in a Cone of Shame and make you sit on an ice block.

Eugene

The Eugene run ALWAYS starts an hour late. They want to make sure everyone has a chance to show up. If you only booked your baby sitter for two hours, well then you don’t know who you’re running with.

There are always two trails, one for fast runners and one for slower runners. They meet in the middle for refreshment. This allows slower runners to participate in an event with faster runners. Of course, sometimes this means faster runners shiver with hypothermia waiting for the slow ones to catch up.  

At the end when you call up people for rewards/punishment, they make sure everyone gets called up for something so they feel included. Never mind a five-mile run just took up 7 hours of your Sunday afternoon.  

Here you get a message to sacrifice your individual needs for the cohesiveness of the group. No one says it. You learn it from the expectations and behaviors in your environment.

Your Context

If I were to guess, you as a therapist are measured by things like vacancy rate and new patients. This means you have a tightly packed schedule confounded by oppressive documentation. So, is now a good time to talk about my feelings around my HEP?

There’s a landmark psychological study from the 70’s that applies here.1 http://psycnet.apa.org/record/1973-31215-001 The authors wondered whether seminary students on their way to give a lecture about the Good Samaritan would be more likely to help someone in need. The control group was lecturing on a different topic. It turns out that the topic was inconsequential. It was whether they were in a hurry or not that dictated whether the students stopped to do a good deed.

If your KPI is vacancy rate, you’ll hurry on by. If your KPI is completed plans of care, you’ll begin to prioritize differently. You will make the time. You will look me in the eye and make sure that we both understand what is happening with my body and that I know we are both committed to my success.

You will share with me either the diagnosis you’re sure about or the hypotheses you’re testing. You will educate me about my body to the degree that suits me. When I come in hanging my head in shame for not doing my HEP, you’ll normalize it [LINK] and we will talk together about how I can be more successful. My input will be required to move closer to a solution.

Until completed plans of care are regarded as highly as vacancy rate, we will see a therapist-centered paradigm persist. If you are a clinic owner, you must keep an eye on the bottom line so you can keep your doors open. Just realize that for long-term success, you must build a patient-centered practice. http://www.ppsimpact.org/new-metrics-success/ So, don’t get rid of your classic measures, just be sure as we move towards value-based care that you get those completed plans of care into the mix.

 

Three Questions to Shift Your Culture Towards a Patient-Centered Model

If I want to get better, it would behoove me to be more honest. If you want fewer self-discharges and more patients who get better, it would behoove you to engage more deeply with me on the changes I need to make for optimal movement and minimal pain. Since you can’t control my behavior, let’s look at what you can do.

If you’re not already, start asking the following three questions:

  1. Does my explanation of what’s going on with your body make sense to you?
  2. Are you ready to build a plan for a home exercise program/workplace modification/behavior modification together?
  3. How do you feel about the progress you’re making?

 

Once you are past the first visit or two:

  1. Do you feel like you understand what’s going on with your body?
  2. What percentage of your home exercise program/workplace modification/behavior modification plan did you complete? What changes do we need to make so we can bring that number up?
  3. How do you feel about the progress you’re making?

 

The first question is to check for their understanding and expectations around their diagnosis and plan of care. Does your total knee think they can run an ultramarathon? What kind of pain is okay and what kind of pain means, “stop?” Should I go to yoga with high hamstring tendinitis?

The second question operates on a few levels. If you involve the patient in their HEP, it sends a message that they are responsible for and capable of being a part of their own healing process. A classic physician model has the patient showing up for a pill and a few instructions. Engaging the patient this way says that they have some control over their situation and that complete dependency on you is not the norm. Empower your patients.

The last question digs beneath that positive therapeutic alliance for what is really happening for the patient. Trust me, they love you and don’t want to say anything negative about you. But if you frame it this way, it gives them an opening to bring to light unrealistic expectations and issues around their HEP.

I would love to hear your ideas on how to create a more patient-centered care environment. I, by no means, have all the answers. After all, I can’t even get up the courage to tell my PT I have no idea what’s happening in my body. Your comments are more than welcome and editing this post based on them is always on the table. Let’s figure it out together.


1 Darley, J. M., & Batson, C. D. (1973). “From Jerusalem to Jericho”: A study of situational and dispositional variables in helping behavior. Journal of Personality and Social Psychology, 27(1), 100-108.

http://dx.doi.org/10.1037/h0034449


For more from Heather and the team at CareConnections, please visit their website by [Clicking HERE].

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Interim Editor In Chief, PhysicalTherapist.com

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