I was recently talking to a group of graduate OT students. The subject was balancing the leadership role of the clinicians with client-centered or individualized patient care. One student asked a question to the affect of, “What if the patient already knows that’s wrong with them and they just want you to setup a treatment plan?” Here is my response: Are you a licensed, expert clinician, or a vendor? Are your services and treatment plans “off the shelf” or “one size fits most”? Do you lead your patients, or do you take orders like a waiter?
Most physical and occupational therapists worth their salt would respond “Absolutely not! We develop individualized treatment programs for each patient.” In reality, many clinicians strive for that. We learn in school the importance of “individualized” or “patient-centered” care. Research shows that patient-centered and individualized treatment plans yield better outcomes and results.
However, sometimes, clinicians find themselves being driven by their patients. They allow the patient’s desires, expectations, and views to overly influence the course of treatment. Sometimes, this stems from poor communication at the beginning of treatment. The patient’s expectations are not addressed and, rather than deal with an unhappy patient (or negative online reviews), the clinician decides to placate the patient. The problem with this is, that it doesn’t necessarily prevent the patient from leaving bad reviews or ending up dissatisfied with treatment. In fact, these patients can be more likely to have a negative experience. By allowing them take the leadership role, whenever it must be taken back, they become upset and frustrated. To prevent this situation, clinicians must lead patient relationships and treatment plans.
In his book The Business of Expertise, David C. Baker describes the difference between “experts” and “supplicants” —as he calls them. Experts lead client engagements. They determine the appropriate course of action and they guide the client through it. Much like healthcare, the role of the clinician is to hear the patient’s symptoms, complaints, and story; then use their clinical knowledge and understanding to determine the source of the problem and develop a range of treatment options. Then, the clinician sits down with the patient to discuss the problem and possible solutions. Together the patient and the clinician determine the best course of action, given the unique circumstances. However, one thing should never change: the clinician should guide the conversation.
Contrast that with non-experts. They don’t guide the patient or lead the engagement. They are at the mercy of the client’s preferences. We’ve all had those patients in our clinics. Those patients that don’t care too much for this exercise or that. They simply want you to do some “massage” (aka manual therapy) and then see them at the next appointment. A true expert clinician manages these patient relationships by establishing themselves as the clinical expert and then guiding the patient through the treatment process.
Given the importance of leading patient relationships, it’s helpful to assess where you stand. Understanding the way you typically handle patient relationships allows you to make changes as you need. Self-awareness if a fundamental element of self-improvement and personal/professional development.
Questions to Ask About Leading Patients
As I mentioned earlier, most clinicians will say that they deliver patient-centered and individualized care. They say that they lead the engagement as expert clinicians. However, there is a difference between providing patient centered (or patient driven) care and simply acting as an order-taker during treatment planning and execution. In fact, as a licensed clinician, it is your professional and ethical responsibility to make sure that you are intentionally guiding and leading your patients through the treatment process.
It helps to reevaluate yourself and your practices to make sure that you’re living up to your professional responsibility to direct or lead the patient relationship and plan of care. Here are some questions to ponder and reflect on when evaluating whether there is room for improvement or areas that need to be addressed.
Do you simply run patients through the mill, or do you take the time to learn about their unique situation?
As I’ve written about here, every patient you see experiences their injury, illness, or dysfunction differently. Patient’s can’t be reduced to a diagnosis or set of limitations to be “fixed”. Clinicians and clinics that lead their understand that there are many factors at play in their patient’s situation. Biological, physiological, social, physiological, and even environmental factors influence your patients’ individuals circumstances. In fact, these factors not only affect their symptoms, progress, and engagement in treatment, they also affect satisfaction and retention rates.
Clinicians that lead the patient relationship and engagement take the initiative to understand where each of their patients are coming from. They take the time to understand the unique circumstances and situations that affect their subjective experience of their illness, injury, or dysfunction.
When you take the time to learn those things, you naturally realize that offering “run-of-the-mill” assessment and treatment simply doesn’t cut it.
Do you run patients through the same exercise program that you run most patients through, or do you create a treatment plan that’s more customized and unique?
It’s very easy, especially in outpatient therapy settings to fall into a rut, where every patient does the same set of exercises. It makes it easier for you as the clinician too. All you have to do is modify the reps and maybe grade the activity up or down depending on that patient’s abilities & tolerance. And in a world where productivity drives many decisions about clinic and caseload management, it’s no surprise that this becomes more common.
However, when productivity and efficiency metrics dominate the environment in the clinic, both patients and clinicians feel the pain. Clinicians burn out trying to hit productivity numbers and running patients through cookie-cutter treatment protocols. Patients lose the human —or person-to-person— experience and service that healthcare should be.
Clinicians that truly aim to delivery patient-centered care, need to intentionally work to develop unique and customized treatment plans. There are of course, some elements of treatment that must remain the same from patient too patient. For example, all patients that undergo a rotator cuff repair will have to comply with the standard post-surgical precautions. Even the early exercises and movements must remain standardized between patients. However, what you can do as the clinician is to allow the patient to prioritize their goals for treatment, and then put together a plan that will help them meet those goals. Allowing your patients to prioritize their goals for treatment improves experience and engagement.
Do you let your patients tell you what they want to do (or what they want you to do) during treatment?
We’ve all had that patient. You know, the one that comes in and says something to the effect of, “Hey, why don’t you just put some heat on me and then do some of that massage and call it a day?” (First of all, don’t get me started on the difference between massage and manual therapy…)
How do you handle patients like that? Many times, you may put up an initial fight to statements like that. Then, after a while —especially on a bad day— you give in. You allow your patient to dictate the plan of care to you. You rely only what your patients want to do (or have done) than what you know they need to do. Now, most of the time, clinicians don’t intentionally let patients steamroll them. It just tends to be easier. It’s easier than having difficult conversations with patients about why they should do this exercise or that treatment. It’s easier than dealing with patient complaints or —gasp!— negative online reviews. If you think about the root of this problem, however, it often stems from a lack of patient-centered thinking and planning. It stems from not wanting to “deal” with the patient’s opinions, feelings or choices. It’s easier to just let them do the exercises they want or provide the manual therapy they’re asking for, than it is to have a conversation about why they do or don’t want a certain treatment. It’s easier to go along instead of digging down to the root of their complaints, opinions, or choices.
Now, you can still guide treatment while letting your patients prioritize their goals (as mentioned in the section above). However, the key is to guide (or lead) the patient and their treatment. This requires that you take the time to understand why they are asking for a specific treatment over another. Once you understand the patient’s motivation, then you can have a conversation with the patient about it. It may require you to provide some instruction or education, or it may require you to make some modifications to the treatment plan. But at the end of the day, it is your responsibility to take the leadership role.
Do you —as the clinical expert— take the time to educate your patient and then collaboratively work to put together a treatment plan that will help them meet their goals?
As just mentioned, part of your role as a clinician is to educate your patients about their diagnosis or limitations, typical prognosis or expected outcomes, options for treatment, the effectiveness of those options, and any risks or precautions associated with them. Part of this involves answering questions, but it can also include other types of communication and education. The way you answer questions, ask questions, or seek information from your patients subtly signals to them the type of information you care about. How you explain and educate your patients can also impact their clinical outcomes as well as experience and engagement in treatment.
After doing the education and finding out some information from your patients, you can’t stop there. You need to use that information to collaboratively work with your patient to build a treatment plan that will help them meet their goals. Your role as the clinician is to provide the information about treatment options & probable outcomes, and then work with your patients to determine which course of action is the best options for that patient. Given that patient’s unique circumstances and situation, their goals, and their dysfunction or diagnoses, what is the best & most effective treatment option? Once you come up with an answer for that question, then you guide the patient in selecting specific exercises, interventions, and modalities to help them meet those goals. Throughout this process, you take the role of leader or guide. Your patient may ask you which option you’d recommend. They may need some more information to help inform their decision.
This process results in a treatment plan that you know has a high likelihood of success and that the patient is more likely to be actively engaged in. And, at the end of the day, that’s what you want.
There’s been a consistent thread in all of these questions. And that thread relates to the human interactions and experiences of both the clinician and the patient during assessment, treatment planning, and treatment execution. As I am fond of saying: Healthcare is a human experience. Part of that human experience involves social interactions, relationship forming, and role establishment. In order to provide the highest quality of care in a way that leads to engaged and happy patients, you as the clinician must take the leadership role in the relationship.
How do you lead your patients? Do you help your clinicians lead patient engagements and relationships? Share any additional resources that you found helpful in the comments below!
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Rafael E. Salazar II, MHS, OTR/L is the president and CEO of Rehab U Practice Solutions. He has experience in a variety of rehab settings, working with patients recovering from a variety of injuries and surgeries. He worked as the lead clinician in an outpatient specialty clinic at his local VA Medical center. He also has experience as an adjunct faculty instructor at Augusta University’s Occupational Therapy Program, as a Licensed Board Member on the GA State OT Board, has served on several committees for the national OT Board (NBCOT), and as a consultant working for the State of Georgia’s DBHDD. He is also on the Board of Directors for NBCOT. He works to help healthcare clinics and organizations deliver uniquely impactful patient experiences by improving service delivery through training & advisement.
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