B. Interface with clinical decision-making
1. Primacy of the patient’s goals
Samantha included an “ah ha” she’d had about the importance of eliciting those goals – insight gained when she’d observed Doug, a clinical specialist, interact with the
Commander. From there she had reinforced for the Commander that the goals driving his care were his to set, not hers. This proved to be the key to solidifying their
relationship and engaging the Commander in physical therapy.
A careful reading of Samantha’s narrative reveals a subtle but important shift in language. Within one paragraph Samantha moves from, “I realized that a large part of the challenge of treating Commander Lawrence had become, not determining what I wanted to work on and how I wanted to work on it, but really in involving [him] in those decisions,” to, “Commander Lawrence needed to determine our long-term goals in order for me to be able to truly involve him in his physical therapy.” (Samantha’s narrative, Appendix C, italics not in original)
This is the first place Samantha refers to our anything, in relation to her work with this patient. Does this shift in language, perhaps unconscious as she wrote the story, represent a shift in Samantha’s approach to the Commander that enabled her to partner with him in treatment he saw as important?
Mr. L is now using the stationary bike for aerobic conditioning. Prior to his illness, he was riding a stationary bike for exercise and… enjoyed riding outside as well. We have started using the stairs as an additional mode of aerobic
exercise, one that is functional and easily connected to his return to the
community. We continue to work on his postural, range of motion and strength impairments, when tied to…his personal goals of returning to jogging for exercise and his work as a professor and with the Navy. He sees these things as a means to an end rather than endless exercises and chores with no benefit to him. (Samantha’s narrative, Appendix C)
Maureen and Geoff, too, wrote about their patient’s goals in ways that
demonstrated how critical they saw them being in relation to their ability to be effective in their physical therapist roles. Where Samantha’s narrative revealed a challenging journey to that realization, these other two seemed to have begun there. This may be due to the difference in their years of experience – Maureen and Geoff wrote their narratives for Advanced Clinician level recognition, as opposed to Samantha’s Entry level. Regardless, what’s important to this study is not the fact that they got there faster, but that they, too, wrote about the important role their patients’ goals played.
Additionally, in their narratives Primacy of the patient’s goal evolves to include not
just eliciting the patients’ goals and using them to drive treatment, but also to the importance of making that process transparent to the patient.
Maureen asked Sam right up front about his goals, and he, as she wrote, “looked at me and asked if I was serious. When he realized I was, he said ‘to be on the
freshman baseball team.’” From there, her story literally revolved around developing a plan of care that would give him the best chance of being able to play baseball and set him on a path in which exercise and airway clearance would be part of his everyday life – well beyond the goal of playing baseball. I share that story in the narrative I crafted, Maureen’s Story: Teaming up with Sam, which I’ve placed at the end of this section.
Another example of the theme, Primacy of the patient’s goals, can be seen in Judge Callahan asking Geoff if he could return to running. Geoff considered it but “felt that due to the repetitive impact to his hip and lumbar spine, running might not be a suitable form of exercise.” Thus, he wanted to suggest alternatives. At this point in his narrative, Geoff shifted to telling the story of a lesson he’d learned with a previous patient.
In the past I have assumed, incorrectly, [a patient’s reasons] for exercise, and found the best way to suggest an alternative is to truly understand my patients’
motivations. I had one particular experience in which I needed to suggest an alternative exercise for a patient… To demonstrate that I had her best interests in mind, I assumed she was doing a certain activity for health and wellness, and she could achieve that with an alternative [exercise]. This negatively impacted our rapport as her motivation was the personal accomplishment, [not] health and wellness. (Geoff’s Narrative, Appendix C)
Thus, before responding to the Judge’s question, Geoff asked him why he ran,
“to which he explained that it was to stay active and healthy.” Discovering that he “had no particular love of running,” Geoff suggested “swimming and biking as alternatives to running and other high impact activities.” Geoff closes this portion of the narrative by sharing his strategy, employed, in this case, to great success.
Encouraging him to continue exercise and respecting his desire to be active enabled him to hear my suggestion for alternative exercises without
defensiveness with the prospect of limiting exercise altogether. (Geoff’s Narrative, Appendix C)
Geoff’s narrative differs from the rest in the way he walks us through his thought process related to negotiating the Judge’s return to aerobic activities. In it Geoff reveals how he consciously used a lesson learned through a mistake made with another patient – not a mistake in exercise prescription, but in assuming he knew why the patient was asking about a specific exercise. By sharing this detail Geoff provides a window into his use of Schửn’s (1983) reflection-in-action: when Judge Callahan asked about running, Geoff considered that earlier lesson and applied it to his decision about how to respond.
As a final example of this theme, Matthew weaves references to Ana’s goal of running the Marine Corps Marathon throughout his narrative. At times revealing to us his frustration at her unwillingness to ease up and allow her back to heal, Matthew never challenged Ana on her goal. In fact, whether discussing Ana’s decision-making about back surgery, or how they would continue her physical therapy while she sought surgical opinions, Matthew respected this woman’s right to her goal. Like Maureen, he
took every opportunity to help her understand the link between her physical therapy and her potential to someday achieve it. In the end, they succeeded together.
Despite minimal training throughout the summer, [Ana] was…determined to at least travel to Washington and begin the Marine Corps Marathon…and stop if she felt she could not go on…She not only began the marathon, she achieved her goal of completing the entire 26.2 miles! Each participant of the marathon was given a small triangular medallion as a reward for completion….Ana presented me with a thank you card and in it was one of these medallions. She told me she asked for three extra, to give to people [who’d] supported her and helped her to achieve her goal. I was lucky enough to be one of those three, in the good company of her mother and her neurologist. (Matthew’s narrative, Appendix C)
While the four preceding examples vary in the ways I’ve pointed out, the common denominator is clear. For each of these participants, the patient’s goal, discovered in the context of their clinician-patient relationship, informed key decisions about physical therapy treatment and its potential for a successful outcome.