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PT and the Greater Good

The Problem-Oriented Approach to PT

Published December 14, 2010 4:15 PM by Dean Metz

I had a conversation today with a nurse of the same supervisory level as myself. We are overseeing the clinical education of a junior nurse. I think it is remarkable that both nursing and physio will oversee the clinical education of either discipline.

We both agreed that this particular individual had a great deal of difficulty with problem-solving. This person tends to follow the recipe approach to patients. In other words, find the diagnosis and then follow the NICE (National Institute for Clinical Excellence) guidelines. The NICE guidelines are all based on evidence and work well for following clear-cut presentations. When was the last time you had a clear-cut presentation?

She had a client who had fallen, had a history of arthritis and an old surgery to her right ankle. She followed the guidelines for all the above, but failed to notice the DVT that developed in her right calf despite very clear symptoms indicating one.

I have had similar issues with physical therapists, nurses and managed care providers back in the states. There is no such thing as a comprehensive assessment to them, only body parts in need of a fix. There is no curiosity to look beyond the diagnosis written by a doctor or by another therapist. There is no such thing as, "What is going on with this person today?" when approaching the patient.

As physical therapists/physiotherapists, we are taught to take a problem-oriented approach to things. This is how we develop our goals for the patient. When I mention goals to most nurses, they have no clue what I'm talking about, despite having care plans (largely ignored) loaded with them.

The group I worked with in New York finally got their minds around the concept, demonstrating excellent results. How do I replicate that in a whole country here?

By the way, I got an "A" on my epidemiology final. Thanks to those who wished me well and gave words of encouragement.


The tunnel vision you mention here seems to pervade all disciplines.  For example, doctors often don't look at the entire person with a plan for problem resolution, but at only the system or extremity with the goal of symptom abatement.

A dear friend of mine recently went to Mayo Clinic after her case stumped doctors at her regional hospital.  In less than 48 hours the doctors had a diagnosis and treatment plan.  Her daughter remarked about the amazing coordination of care her mother received.  It made me wonder two things.  First, how much better off would patients in America be if this coordination of care existed on a broader level?  Second, why doesn't this level of coordinated care exist on a broader level?

Still, even with this coordinated care, they still missed a very obvious problem.  The doctors were frustrated that she was not up and moving more while awaiting surgery.  The problem:  the medicine was making her sick; her gastric issues were leaving her stomach empty which was why her meds were making her sick.  It was a vicious cycle.  The combination of a lack of nutrition and general exhaustion from the heart condition and gastric symptoms left her in a weakened state which made moving around next to impossible.  

So, while the doctors coordinated their care, apparently there was little coordination between disciplines (doctors and nurses).  All that just to say, you aren't in this alone.  That fact that you could effect positive change even in one segment of the medical arena will have tremendous impact.

Congrats for getting the PTs in NY on board.  Replication in the UK won't come easily-or quickly, but you have a template from which to work.  Keep your eye on the prize.  The result will be worth the effort.  Who knows...maybe you'll figure out a way to make the template into a continuing education course for all disciplines.  

Janey Goude December 20, 2010 12:06 AM

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About this Blog

    Dean Metz
    Occupation: Staff Development Specialist
    Setting: New York, NY – Newcastle Upon Tyne, Great Britain
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