Critical Thinking

Patients dont hate us; don’t set them up to.

“My last PT told me that I will hate them by the end of their treatment.”

I heard this statement from an elderly patient last week.   This patient had a total hip replacement, quickly followed by a fall, resulting in a fracture and ORIF of her femur.   

Through our initial discussion, the patient implied she expected our care to make her really, really sore.  She had an expectation set by a previously seen clinician.  But why?


 

Patient expectations  predict outcomes from care

Following the interaction, I tagged this patient’s quote to my Facebook account.  I quickly saw multiple interactions from PTs and students who were either discouraged or supportive of the PT who set that expectation.

“How could anyone support this statement?” I thought.   Well, its likely not their fault.  It’s instead a failure of the focus of their education (heavily weighting bioanatomical fixes vs. human interaction).   I’ll discuss that in a future post…


 

For those interested in my initial concern…and those who treat humans…

In 2011, an article in Pain highlighted the effects of presurgical expectancies on the postsurgical outcomes in individuals who have undergone a total knee arthroplasty (TKA). The study measured:

1. Pain and function via the WOMAC

2. Comorbidities effects on outcomes

3. Pain-related fear of movement via the Tampa Scale for Kinesiophobia

4. Depressive symptoms via the Patient Health Questionnaire

5. Expectancies via four questions (“How likely is it that one month following surgery; your pain will have decreased? your sleep will return to normal? you will have assumed your household responsibilities? you will have resumed your social and recreational activities?)

6. Pain Catastrophizing via the Pain Catastrophizing scale .

The authors of this study found psychological factors to have a significant prognostic value in predicting post-operative pain severity and function following a total knee arthroplasty. Presurgical pain catastrophizing predicted poorest recovery, along with pain-related fear of movement and depression.

So, should we set up an expectation for pain?  Should we tell the patient they should hate us?   No.   This language demonstrates a sense of negligence, when considering the psychosocial variables which influence outcomes. 


 

 

Cultural Interdependence 

In 2014, I introduced the concept of cultural interdependence.  This was my term to describe the influence of society and culture on pain.   Around the same time, on body in mind, there was a discussion that involved Dr. Mick Thacker, out of Kings College, who proposed that himself and a colleague came up with the following definition of pain:  an embodied element of suffering encapsulated by an  experience of the person within the society and culture in which they live. 

To better educate the consumer, we need re-define and re-educate the consumer about why their knee may hurt but not set expectations that we will make them hurt.

I provided the following cascade of variables which may influence pain before and following a knee replacement:
1. A cultural expectation exists that indicates, “arthritis” = “pain”.
2. The input of  “words” by the practitioner to the “patient” (ie. your knee is the worst knee I have ever seen…)
3. An over-utilization of diagnostic imaging, giving a lay individual, who has no education in radiology, the ability to “visualize”
(another input) their “severe” arthritis. “I saw it, therefore, I  believe“.  The practitioner responds again, “This is why you hurt”.
4. The somatosensory influence of a practitioner provoking their pain either before or after 2&3 (another input). “This is where it hurts, isn’t it” vs. using more accurate language such as “what do you feel when I touch here”.
5. A healthcare system that reimburses based upon procedural codes and a joint replacement  system that capitalizes on 1 & 2 & 3 & 4
6. A perception of healthcare that assigns “weights”  to certain practitioners and their “abilities” (ie. generally an orthopedic surgeon is weighted higher than PTs by the lay individual in treating a pathoanatomical diagnosis of “knee OA”).
7. The societal reinforcement by family members and friends (more input) that knee OA does not respond to PT and they themselves had to undergo a knee replacement to get rid of the OA.
8. An association that assigns completely unrelated variables, such as the weather, as influencing variables on their symptoms (this is a cultural belief that has not been substantiated in research).
8. More visits to a physician, often resulting in more input (chemical) via cortisone, which is a steroidal anti-inflammatory, for a non-inflammatory based condition  (does this make sense?—-for those with less medical training, osteoarthritis is not categorized as an “inflammatory” disorder)
9. I am sure 1-8 have some powerful influences over the cortical representation of that joint.


 

So in reading this, should our patients “hate us”?   Is this “just a joke”?   Or is it a variable which may influence your outcome?

Sullivan M, Tanzar M, Reardon G, et al. The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty. Pain 2011.


 

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