On my musculoskeletal outpatient placement I encountered a client who presented to the department seeking treatment for a recently sustained shoulder injury, however on questioning the patient also stated a number of different painful areas- the cervical spine, lumbar spine and knee. When questioned further, the client stated his main problem was his knee pain which had been present for a number of years. Therefore between the supervisor and myself a decision was made to initially concentrate on the knee problem. We decided this as there was not adequate time to assess each problem since both the shoulder and knee indicated a degree of referral from the spine. This decision was discussed with the patient and he agreed to proceed with this line of thinking. However as the assessment and treatment wore on I started to pick up on non verbal cues that indicated the patient was not happy with this direction and would have preferred us to concentrate of the shoulder. Throughout the session I became increasingly uncomfortable as I felt the client was not satisfied with the direction of the session and this started to lower my level of confidence in my treatment. This situation arose due to miscommunication between myself and the patient as to expectations from physiotherapy treatment.
Previous to this incident I would have assumed the question “what is your main problem?” would be sufficient to direct assessment in a direction satisfactory to the client. Due an assumption made by myself and my supervisor, the patient may have been unhappy with the level of treatment he received.
IN THE FUTURE I WILL ENSURE PATIENTS WHO PRESENT WITH MULTIPLE SITES OF PAIN ARE DIRECTLY ASKED WHICH PROBLEM THEY WOULD LIKE TO BE ADDRESSED FIRST TO ENSURE NO MISUNDERSTANDING OCCURS. THIS ENCOUNTER EMPHASISES THE NEED FOR A THOROUGH EXPLANATION OF THE THOUGHT PROCESSES BEHIND OUR ASSESSMENT AND TREATMENT TO IMPROVE PATIENT’S CONFIDENCE IN OUR INTERVENTIONS. IT ALSO HIGHLIGHTS THE NEED FOR PATIENT INVOVEMENT IN DECISION MAKING AND GOAL SETTING.
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2 comments:
That's a good point. I think that if the patient is not satisfied with the approach taken, or if he/she does not know why this approach is taken, then it is likely that he/she will not be compliant with self management and/or the home exercise program. I feel that the patient will be more satisfied (thus the treatment being more successfull) if the problem he/she wanted to be resolved was addressed initially. I think this will make the patient happier and more compliant with the treatment.
Patients presenting with multiple areas of symptoms is a common occurrence in outpatient musculo. I feel its important to clarify the "main problem" as you did and from there clarify that the subjective and physical exam on that day will concentrate on that area. I think some patients can nominate a "main problem" but still expect you to assess all areas on day 1. Explaining to the patient why, initially, the assessment will concentrate on the main problem or area is important, along with reassurance that other areas of concern can be assessed thoroughly on another occasion. It is very good that you picked up on your patients non verbal cues that he/she was not happy with the direction the assessment was taking. Hopefully this will build your confidence to address those non verbal cues earlier (as soon as noticed as opposed to continuing on with the direction you are taking) and question the patient as to what is wrong and then explain then and there the approach taken. Any miscommunication issues can then be solved early on so the patient is satisfied from day 1.
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