Episode 43: Avoiding a Negative Patient Experience

Richard: Welcome back to Agile&Me a Physical Therapy Leadership Podcast. I have the pleasure of welcoming back Joanna Bailey. Welcome. Joanna was on a prior podcast talking about her positive experience recently with physical therapy. And what I wanted to do was talk to you today unfortunately about perhaps experience that wasn't as good. And I always believe that we can learn more from when things perhaps don't go quite right than perhaps when things go very well. So certainly, don't want this to be a negative experience but definitely we can learn from hopefully interaction. So, before we dive into perhaps what went poorly with your physical therapy, Joanna, could you perhaps tell the listeners a little bit about the, perhaps at a very high level what you were planning on seeing the therapist for and you know, just any general comments about the episode first.

Joanna: I had been dealing with some lower back pain, hip pain and have been a very active. I was in my early mid-forties and, was really frustrated about the limitations on my activity. An MRI was sent to a pain clinic. Finally, after a couple of pain injections, I said, I don't want this anymore. Would you just order some for me? They did. I spent about. Five months in PT. And did not get better, which I thought was there was just not a lot of progress at all. And I eventually had to get a referral again from my PCP for another MRI And they did a different, they scanned a different part of my body and I needed to have a hip replacement and I was a very young hip replacement patient. So, I think if I had to talk about what, identify kind of what didn't go well, it was the sense of not measuring progress regularly and also kind of sending me through strengthening exercises that I could do, but wasn't fixing the problem. It wasn't about the exercises. It was about. The forward motion that I wasn't able to be diagnosed. So, I think it really was, when I look back on it, it was not adequate assessment and reassessment of the problem, and I did not have confidence in that office as a result. And to the defence of the therapist, they didn't have the MRI of my hip yet. So, they didn't know that I didn't have any cartilage there, which they couldn't fix that. But that was, I think that was frustrating. And I've talked to other patients who've had similar experiences. So, I don't know. I don't want to blame it all on the therapist. I didn't feel that sense of partnership with my PCP to say, you know, she's really not making progress. She's walking all day and she's still in pain and she's too young like somebody. I wanted somebody to say to me. You're too young to have this right now. You're chronologically not in order.

Richard: I'm sure it was extremely frustrating for you through your care because I would imagine the fact that you were had. I would imagine the pain for a reasonable, considerable amount of time even before you got to therapy based on the care that had been provided, the providers that you'd seen I would imagine probably based on the fact that it was ultimately the hit, probably the amount of communication or education was probably limited. I might be speaking out of turn there. So going into therapy, I'm sure you had quite a lot of anxiety and frustration generally. Is that probably, is that fairly accurate?

Joanna: Well, I was really hopeful because I had almost 20 years prior to that had an ACL repair and so I had nine months of physical therapy after that. I knew what progress looked like. And while this wasn't a surgical piece yet, it didn't. It wasn't moving in that direction. And again, with my health care background, I know just enough just enough to say, if things aren't getting better, we might be treating and we might be treating the wrong problem.

Richard: Yes, if we got a little bit of granular level, how was your interaction with the staff? Was it purely a clinical reasoning issue or was it really was there, I don't know if dissatisfaction is the right word, but were there concerns with regards to the experience on the whole?

Joanna: Yeah, the experience on the whole wasn't good. In the last episode, we talked about the engagement of the therapist, and that was not that was not evident. In this situation there was a sense of, we can try to figure out what you can do to get better and to get stronger, but there wasn't the professionalism of you know, of that hands on there was very little manual work done in that office and they seemed more interested in talking to each other and or working with younger patients who were there for like sports medicine or for high school sports issues. And that so the atmosphere in the clinic was not as conducive to the kind of patient I was. Where I was really trying to live my life.

Richard: I think as a patient, you can tell very quickly, can't you? If somebody is just kind of going through the motions. And again, we talked about engagement a lot in the first episode, but that's really what it's about, is if you know that the therapist or your provider isn't 100 percent engaged, then how can you as a patient be 100 percent engaged as well, correct?

Joanna: Yes, and the therapist by memory of that office was that the therapists were standing at their computers more than they were actually working with a patient. And so, it was document, they needed to do documentation and they needed to do all these things. And so, there was less connection with the patient, so that and that's a constant conversation in health care right now related to, you know, how much all the documentation that's required and yet the way that we were scheduled there was very different, and we spent less time in the actual clinic than we do at Advent. So, they were shorter visits they were not as I did not feel like it felt more perfunctory than it did.

Richard: Yes, I think documentation is an interesting one, isn't it? Because it's the bane of every healthcare provider life. And necessary evil to get paid. I think to me, it's also how we how we talk about it. And when we do it within the kind of the treatment session. Also, how we do it. So, for instance, you know. If they're stood behind the computer all the time and they use it almost as a physical barrier, if they're talking at the same time as writing to you and trying to do from one hand a manual therapy, one hand a writing almost or talking to colleagues on all, whilst they're communicating, whilst they're writing and not necessarily engaging with the patient, it's more of a I think oftentimes it's not so much the fact that they have to type, it's the fact that their overall communication with the person they're treating, the patient isn't as good as it should be. And I think as a patient, it's easy to say, well, it was the fact that they're on their computer. I think oftentimes that that is one broken piece of communication. Would you perhaps agree with that?

Joanna: There are ways to there are ways to involve the patient in your documentation. And so that's a piece of being able to say, I'm going to pause right now because I want to make a note about you doing blank, blank, blank. I joked with 1 of the therapists. Last week, and I said, I want it noted in your record that I did 15 reps of this when you only told me I had to do 12, you know, and kind of joking with him about it. But to that point, saying, I'm writing a note here. How these are some of the things that I want to say here. And I think that's a way to your point about being able to communicate with. How can you communicate with the patient and at the same time do the bane of our existence, which is document and that's been a helpful thing that I've learned.

Richard: Yes, I love it. You know, your perception of documentation would have been completely different if the therapist said, what you said was really important then. I think, based on what you've said, I think it's really vital that I write this down as, as you're saying it. Perception would have completely done a 180, wouldn't it? If they'd engaged, you. I'm not saying that you can do that all the time, but, but certainly, as you say, if you, And the more engaged they are with you communicative with you, then I think the more tolerance there is perhaps for that, that necessary evil. The other thing that I found is oftentimes the lesser qualified therapists, so less experienced, sorry, not lesser qualified, but less experienced therapists or providers can actually generate better patient experience because. They might not have the clinical skill and reasoning experience that older therapists have, but they have stronger, they depend on, and they use social, sorry, soft skills more and better. And from a patient perspective, that's equally important, and we kind of touched on this as well, this idea of psychosocial component, is treating that is just as important as the physical side. So, I'm sure that the experience you had, unfortunately, probably by the sounds of it, not only didn't address the, the actual underlying mechanical Cause but probably didn't truly engage you on the on the kind of the psychosocial side, correct?

Joanna: Correct, yeah, there was no relationship there that we developed. There was no rapport. I trusted them to the extent that they were employed there, but there was not that relational care and relational trust in place.

Richard: The concept of time is a very interesting one. I believe when we talk about care. A lot of therapists will say that it's important that I'm with the patient all the time. And you know, it's one on one care and they believe that that care is diluted if there's a second person that they are treating at the same time, they're kind of multitasking to a certain extent. Time doesn't necessarily equate to quality. That isn't because you can have a therapist and if they're engaged, it doesn't matter how little or how much time it, it's academic. They're just not getting a good experience. Is that fair?

Joanna: It is, you know, I joke with them and say, if you give me 5 exercises to do in a row, then I won't have to interrupt you. I won't have to go get in your field of vision and go, hey when they're with their 2nd patient. I think to that point is, if we've had, if I've had my kind of my time with them to have that manual therapy or to check in and to check in and then that time gets diluted by the next patient or another situation that that needs more supervision. I don't need a lot of supervision and, if I've had that connection, then that I have a, I still have a good perception of experience because I've had that. The flip side is if I've had that 1 on 1 time, but the therapist is trying to direct another patient at the same time where she has to point so, which means she takes 1 hand off me in order to point or then she's, having to manage another therapist patient because something else has gotten out of whack that actual one on one time has gotten diluted. So that quality has dissipated. For that episode, I try to remember that that's an episode there and not the whole thing.

Richard: Yes, I think if you have confidence, if you have a truly engaged clinician for the manual therapy component and the assessment, revaluation, reassessment type of component phase of the treatment there, if they're hyper focused on you. Even when you are semi-independent with exercises, you know that they are there, they are engaged, they are committed, and if there is an issue with the exercise, you know that they're immediately going to step in. Whereas if you don't have that engagement from the first part of the treatment, then the confidence in knowing that you are still important, even though you might be semi independently exercising is not there, is it?

Richard: We talked a little bit about the patient, the clinician interaction. I often find that if one part of the care is not meeting expectations, then very often it's the entire episode of care. So, it's oftentimes the facility rather than just one individual. Is that fair to say in your experience was there, did you feel that there was just one component lacking or did you feel that they kind of just missed the mark on a number of the pieces of the whole care episode?

Joanna: I think I saw them. I saw them missing the mark, not just with me, but with other patients. So just the quality of what people were experiencing there. They were all doing things. I mean, we all had things we were supposed to be doing when we were there. It just didn't have a sense that that people were happy to be there or that they were making progress and that and it's, the locations of the clinics are not very far apart. So, there are different companies, but they're, not very far apart. So, it's not even like, it's a different part of the United States or different part of the city. So that it really boiled down to, were they happy as colleagues to be there. Or were they really just kind of putting their time in and doing the I think I was there during March madness. And so, I had to, you know, there was just more there was more focus on things that were happening in the outside world than the fact that we were all there trying to get. Our bodies in better condition.

Richard: It's amazing, isn't it? The geographically close and they're licensed clinicians, but the atmosphere can be completely different content. And then I always find is if you walk into an atmosphere that's not very positive. Then you as an individual will tend to gravitate towards whatever that atmosphere is, isn't it? You know, if it's a kind of a negative atmosphere, you walk out and almost feels you've got to have a shower almost. Whereas when there's a positive atmosphere, you come out and it doesn't really matter what happened. You might have been sore, but it's, hey, great, you know, bring it on. I can't wait for the next treatment session.

Joanna: So, it's a contagiousness. And, you know, everybody's entitled to a difficult day, and everybody's entitled to things. But generally, you don't have 10 people who are all are having a bad day on the same day. So, somebody is going to come in and mix it up a little bit.

 Richard: Were they similar of the good experience and bad experience? I assume you still had to get a referral, do the registration documents, ring up you know, have an evaluation, re-evaluations, et cetera, testing. So, I would assume it wasn't the whole.

Joanna: Yes, things were done differently only in that there was just very little manual therapy. And so that was, that was, that was the main difference.

Richard: Now, based on our conversation, you advocate for yourself, which is fantastic. I would assume that during this five-month period you probably more than once expressed concern with regards to, I'm not making progress here. Or, hey, this isn't working or, or I don't feel positive how was that met how was that managed and was it a positive experience or was it just kind of brushed off or did it actually the experience you got back or the response you got back kind of. Pulled you down even further, perhaps.

Joanna: Don't know that it pulled me down any further. I probably reverted in my personality to kind of saying, well, I'm not going to sit here and wait. I'm going to reach out. I had a good relationship with my PCP, and I can do that. The ways in which the clinic itself wasn't helpful was that they would, they would listen to me, and they would kind of say, okay, well, let's try this. And so, they would just try something else, at the time, you know, I can look back with it with 2020 looking back. I look at it and say, why wouldn't they have like, tested other things in my body rather than just keep focusing on the on this 1 thing. Or to have felt empowered to say, I'm going to send a note to your doctor because I think they need to see you again. And I think they need to order something else, order a scan. So, it didn't feel I didn't have this experience of the therapist being a peer with the physician and that that's what I that's what I felt. Probably what I needed. So, I took that role instead. I'm going to go back and do that.

Richard: Yeah, that there really needs to be that collaboration, doesn't it? Between each stakeholder. And that's usually the patient, the therapist and the referring physician. And I think where care episodes break down is when there isn't that relationship. The other thing I think is where the patient, the therapist is somewhat passive. Now, I'm not saying that therapists, should dictate care or should direct care without collaboration with the patient, but patients do, patients aren't physical therapists and they do need that. guidance and they do need direction and I think sometimes practitioners will say, well, you know, let's try this or and we'll keep it the same until the patient, the patient self-discharges or says something and say, hey, you know, we need to do something different. And ultimately in your case, it sounds as if you, you actually took the lead of your own care and, and so, you know, discharged based on further testing. And my impression is if you went gone on for five months, they would have probably still continued to treat you and be in limbo if you hadn't actually advocated for yourself through your primary care provider.

Joanna: For sure.

Richard: Do you believe, that they were not operating at a level that really I would, as a consumer, I would expect did you ever get the feeling that, or did they verbalize there, their just discontent with being there, or did they outwardly negative at all or was it more just kind of a more of what wasn't said, and what just what wasn't done,

Joanna: I did not get the sense that there was a leader on site or that there was leadership there. And I knew the. I knew the organizational structure such that I knew that their manager managed multiple sites. And so that was, you could tell that there wasn't a lead therapist, they're kind of taking charge and kind of having that. That sense of ownership on the quality of what was happening there. And that was, that was more evident to me. I don't remember getting surveys for that that site. I might have, but I, I don't recall and. I don't know that they were actively working on anything to improve or what they were identifying they needed to do. It was a very passive office.

Richard: It's incredible, isn't it? That I firmly believe that the tone is set by, by manager or leader. And without that, then it becomes almost rubble less. And just really drifting and I think that based on what you've told me already, I think that definitely was reflected in the treatment as well. So, I think good organizations are not micromanaging, but certainly leading. And facilitating and engage with their employees and everyone within the organization. And part of that leadership, I believe, is seeking feedback from patients. I know we were kind of talking about the experience, but that didn't go so well. But more recent experience. Did you feel that there was opportunity and times to provide your feedback? Did you feel that that was. Asked for and then taken seriously as well when it, if and when it was given.

Joanna: And there was a sense of, there was a sense of kind of moving people through and that quality and message was evident there. I don't experience that currently. So, in my current treatment, and so that's definitely a difference of experience.

Richard: And then with your current episode, I know that you would have got you know, online request for reviewing your experience probably two or three times, even at this episode of your care. And I know that there was a couple of times where you had to mention something to the clinic leader or to a clinician about what you saw within the clinic. Did you feel in your current episode that, that they took it seriously and then acted upon it at the first opportunity they had?

Joanna: I don't know whether they took it seriously. I don't know whether they acted upon it. And I wouldn't expect necessarily to know, because I know it's really more of a personnel issue. And yeah, so I wasn't, I didn't have too much concern about that. And I do sense that people want to know and get feedback in this environment, and they don't, they don't see it as an affront. if it's provided. So that also makes it more, I feel more comfortable offering it. If they're. That they're seeking it out to finish.

Richard: To finish, based on your broader experience within healthcare, I'd love to know your thoughts on what's really the key difference between a good experience and a bad experience. I know there's lots of different things, and that's probably a very unfair question in a way. But you know, you've definitely experienced many providers around you and how they've, how they delivered care and, and I'm sure vast majority of had, have been great experience for both the provider and the patient, but there's definitely, I'm sure enough times where you can quite clearly understand and differentiate between what's required for a good experience and a bad experience. How would you perhaps frame the two now, either saying this is what you need for a good one, or this is this is the tend to be the indicators or the factors for a bad one.

Joanna: So, a bad one would be I've already been a patient there and the clinician has to ask me again why I'm there and what they need what I've been working on. I essentially have to help them take care of me and a really great one is when I'm listened to for at least a few minutes. So that somebody really understands what I've been experiencing. Even if it's a silly thing, like, it really hurts when I do this. And because that then helps them know that this isn't just about that she can't play adult softball anymore. It's that she can't do this activity that she just needs to do every day, or it interferes with her life. So, really taking that time to listen and hear me and know my case, as opposed to having to have the patient review over and over again.

Richard: Well, thank you so much for sharing your experience. Hopefully the episode that didn't go quite so well. Has not tainted your perception of therapy. Overall. I apologize on behalf of the profession that we missed the mark, even though it wasn't one of my clinics. But as a whole profession. Overall invaluable insights, and I'm sure the leaders that listen to the podcast will all think so as well. So, so thank you for your time today.