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Toni Talks about PT Today

Respect for Clinical Judgment

Published December 20, 2011 6:14 PM by Toni Patt

Once in a while I work with patients who have a diagnosis other than stroke. Two or three weeks ago, I evaluated a young man who'd had a TBI and was in the ICU. I later re-evaluated him following transfer to the rehab unit. Last week his rehab doctor noticed he had some ROM issues and decided to address them. Because I was the evaluating therapist, I was included in the discussion.

The treating PT acknowledged the deficits but denied functional impact. A discussion ensued. In an ideal world, one would hope since the PT denied functional impact that would be the end of it. Instead the physician insisted something be done and wrote an order for serial casting. The PT's opinion was ignored because the doctor disagreed.

This raises some questions. Why treat something that isn't causing a functional impairment? Better yet, why ask the PT's opinion if you're not going to listen to it? The PT told the doctor the deficit wasn't enough to cause a problem. She also didn't think the patient would tolerate that treatment. The doctor wrote the order and as of today is continuing to insist the casts be continued.

For all the good it did, the PT might as well have not been there. It would have cut down on her anxiety level. This isn't the first time this particular doctor has done something like this. I'm actually kind of surprised the PT was allowed to voice an opinion at all. The point of having interdisciplinary meetings is to enable everyone to work together to decide what is best for the patient. That means recognizing and respecting each person's clinical knowledge.

I've worked with many physicians who don't understand what I do yet they respect me for doing it. If I tell them a patient needs something, or conversely doesn't need something, my opinion is respected. I don't think the rehab doctor has much respect for therapies. Maybe this was some sort of power play to prove who is in charge. Or maybe our rehab doctor doesn't have a clue. It sounded like a good idea at the time and now it's too late to back down.

This is a lose-lose situation with the patient coming out on the bottom. He is undergoing a painful treatment he doesn't like to treat a deficit that wasn't causing a functional limitation. The doctor has lost even more respect. The PT feels disrespected because her opinion was ignored. Management isn't doing anything, including confronting the doctor.

I think we know where I stand on the issue. It's probably a good thing I'm not in management. It wouldn't be so bad if some good could come of this. Unless someone in authority addresses this with the doc, that won't happen. It's just a matter of time before it happens again.

6 comments

Jeanne,

You are welcome.  You're right - never too late to learn and grow!  I'd love to hear your thoughts on the book.  Oh, I got mine from the library - so it was free!  In this economy, every bit helps!

Jane Goude December 30, 2011 9:31 PM

Thanks for the info Jane. I haven't logged on to the blogs in a while. Too bad I didn't have this book to read early on... like 30 years ago (!) but since I'm still "in the game", it's never too late to start... to read a good book, that is ;) .... and then put it to good use!

Jeanne December 30, 2011 12:51 AM

Jeanne,

That's what I've been doing on my blog - each week is a nutshell.  This week was week six, so we're almost done.  

The first week I explain the dysfunction:  what it looks like and its consequences.  The next week I describe the tools that a team can use to work toward healthy function in that category.  My Dec 21 blog(http://community.advanceweb.com/blogs/pt_4/default.aspx) lists the tools a team can use to work toward commitment.  

The problem is, you can't start there.  At a minimum you'll need to read the week before to get an understanding of what team commitment does and doesn't look like.  

Truthfully, to be effective you'll need to start at the beginning, which is Nov 9 (http://community.advanceweb.com/blogs/pt_4/archive/2011/11/09/team-dysfunction.aspx).  The reason commitment is a problem is because the previous two components are dysfunctional, preventing commitment from taking place.

Each function builds on the next.  You have to have the first in place before you can work on the next one.  Lencioni's book is an easy read.  I don't like to read and I made it all the way to the end :-)  I think I read a chapter a night and made it through in about 2 weeks.

Good luck!

Jane Goude December 22, 2011 2:52 PM

The therapist's opinion was not considered in thi case. The team is not functioning in this case. I have been there.

 Jane, can you give us the "tools" in a nutshell enabling us to deal with these situations better? Some of us do not have the time to research all of this and would really appreciate some tips. Help!

Jeanne December 22, 2011 2:14 PM

Toni,

I hear your frustration.  Because of the series I've been doing, I'm seeing things a bit differently.  I'm not sure the core issue at play is actually the doctor's choice of treatment.  Patrick Lencioni wrote a book, "The Five Dysfunctions of a Team" which lends insight into the situation you describe.

Lencioni points out that it is not incumbent upon the leader (in this case the doctor) to do as the team members (in this case the therapist) say, nor is it reasonable for team members to expect to get their way.  As a team member, what is reasonable is to expect your opinion be taken seriously.  

Lencioni suggests that when a leader is skillful at relaying this sense that team members' opinions are being seriously considered, then team members can commit to the decision - even when the decision is contrary to individual team members' personal opinions.  This level of committment is called "buy in".  Obviously "buy in" isn't happening in the case you describe.  

There are various reasons this level of committment may not be occurring.  Some of them are covered in the last five weeks of my blogs.  Unfortunately, without team committment, higher levels of teamwork are unattainable.  Those will be covered in weeks to come.

Last week's blog on the dysfunction of team committment may offer additional insight into your sitation.  Patrick Lencioni's book, "The Five Dysfunctions of a Team," may give you and other team members tools you could use in interacting with this doctor.

Best,

Jane Goude December 21, 2011 8:36 PM

After having practiced for many years and in various parts of the country, I have had the benefit of working in a team oriented practices/environments and the sheer frustratoin of working in a less progressive ones. Keep making your point, respectfully of course, and focus on the patient. You are not going to change this doctor or that type of thinking. That doctor may change when/if management does stand up! Trying to get management to step up is a whole different ballgame. I was not able to do that and it is why I chose to leave management behind and focus on the "hands on" in another setting . It has worked for me. I hope you have more days that are truly satisfying and experienes like you describe above lessen. Your passion comes through.

Jeanne December 21, 2011 8:59 AM

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