Many of the things I make up usually start out as a joke. I made a PowerPoint presentation on how central scheduling should use astrological signs to better match patients with clinicians, including compatibility charts and some other statistics. I’m an Aquarius, so my most compatible signs are Aries, Gemini, Libra, and Sagittarius. My least compatible signs would be Taurus and Scorpio. My main argument was that it is “a” system, versus the current system, which was “no” system. I challenge you to waste more time than me.
When I first made up this flowchart, it was titled “How to treat crazy patients.” I made it in response to colleagues that complained about “crazy” patients they “could not get rid of, and how did I seem to have less “crazy” patients on my caseload. Reason #1 was that I don’t call patients crazy, so I can’t have a bunch of things that don’t exist on my caseload. Secondly, there is no difference between treating crazy versus non-crazy patients since they are both humans and have the same rehab needs. Also, if you’ve been involved in patient care for a prolonged period of time and still refer to patients as “crazy,” that means you have not really mastered 1) communication, 2) empathy, and maybe 3) confrontation.
Unless the person has an actual mental disorder that will affect compliance. Even then, “crazy” is probably the wrong word. Your “crazy” patients are just challenging to you because YOU haven’t figured out the best way to relate to them. You may never, hence the flowchart to narrow down the actual treatment options you have at your disposal. As YOU get better, the options at each decision point will expand. So, get better.
The Patient Treatment Flowchart (PTF)
Treat ’em and Street ’em
This was an adage I learned as a student. When I repeat it to other clinicians, it is usually received as a negative, like I’m denying people access to rehab. Not true. All it means is don’t waste your time and more importantly the patient’s time doing things that aren’t progressing towards the goal. My longest evaluation was a little over 2 hours. My shortest evaluation was -10 minutes. Yes, MINUS, I STREETED her in the lobby. The biggest thing I got out of her chart review was she was a smoker on oxygen and didn’t feel like she needed rehab. Her referral was for shortness of breath. She was early (public transportation), so I entered the PTF with “why are you here?” I learned she had no problems with day to day activities, and was not interested in exercise. Would rehab have helped her? Probably, but not as much as quitting smoking, which she also was not interested in. So, I STREETED her.
STREETING involves more than just showing someone the door. It involves a physical therapist’s most powerful tools – exercise, advice, and education. We talked about the benefits of walking more, ask her if she had the resources to quit smoking, and told her that the clinic is always open if she decides she wants to start an exercise program. I then stamped “STREETED” on her sheet and gave it back to the ladies at the front desk for their daily laugh at my expense.
Let’s break down the parts of the PTF.
“Why are you here.”
Pretty straight forward. BUT, it’s a trick! For those people that are fans of motivational interviewing, this is actually not a great questions because “why” questions judgement. Why did you do that? Why are you angry? Why did you wear that? No one like’s their judgement questioned, and it will immediately put someone on the defensive. So ask why without asking why. What brings you here? How can I help you? I like “How can WE help you?”
The WHY needs to be very specific. The more specific, the better you can guide the person. I like it to be a specific task, then the bulk of my assessment is them doing that tasks. The task is important because not being able to do it prevents them from being the person they are suppose to be. Remember that whole ICF Model stuff in PT school you thought was stupid? So did I. Turns out it is pretty useful.
Pain is a common answer, but rarely the “why” since they will likely say the pain started 2/4/6 months/years ago. “My ____ sent me” could be a family member or physician. Sometimes it is straightforward, sometimes they’ve been to a bunch of providers and you are the final landing spot. Keep in mind that there is a big difference between “I’m worried about you, go here” and “I’m worried about you, let me take you here.” Remember that when you tell a friend or family member they need to go somewhere. Obviously the physcian won’t come to the appointment with the patient, but you can see how “my _______ sent me” isn’t a good starting point.
Should this person even be there?
A medical problem is something that prevents progress towards the patient’s goals. A medical treatment would be medication, surgery, and maybe imaging. Your history and exam determine medical problems. You have to know how to take a good history, rule out red flags, pick clusters of special tests to confirm a diagnosis, and understand if the diagnosis you confirmed is even relevant to that person’s goals (since special tests aren’t special…). An example is a rotator cuff tear – your tests may confirm it, but does that equate to a medical problem that warrants medical treatment? It is perfectly acceptable to TREAT (start exercises) and STREET (refer out), but you should explain all of the options to them.
Be aware that medical problems can affect range of motion, manual muscle testing, and all the initialed evaluation systems (MSI, MDT, SFMA, etc) you have learned, but these assessments don’t prove the existence of medical problems.
BEING STRONGER
I think being stronger always helps, but it isn’t always necessary. Sometimes you need rest. Sometimes a different movement. Sometimes a better movement. Sometimes permission to move. Sometimes exercise, advice, and education. A big reason I can relate it back to strength is I know how to train around an injury.
And I’m talking for real stronger, progressive overload. And the person needs to understand that it will take work and time (months not weeks) to actually get stronger. Once they know what is involved in getting stronger, they have to decide if they want to go that route. Otherwise, I’m just treating them against their will. If they do, great, and you’re at the end of the flowsheet.
3FN 