PT Crab 🦀 Issue 170 - Best of Everything Else

It’s about time for new content but we’ve got one more best of edition to go. Next week, I’ll be moving to a new platform as well so you’re going to see some changes ‘round here. It’s going to look different and smell different, but the gist of it will be the same. There may be some growing pains. You may get some weird emails about your subscription, don’t fret. This is a one man operation and this man may do things wrong along the way. But it will work out for all of us.

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With that, let’s dive in!

Here’s the table of contents this week:

• Editorial about LGBT issues in PT
• Increase self-efficacy in your patients
• Get patients to do their HEP
• Deal with inappropriate patients

An Editorial

Before we dive in to this one I’ll tell you two things. 1) It’s long. Because it’s a topic that’s important to me. And 2) it’s important to me because I identify as bisexual and queer, so this is a topic area I hit regularly and think matters.

The Gist - We open with a type of piece that I cover about once per quarter here in PT Crab, the Editorial. This one is from PTJ in 2022 and is written by Gail M. Jensen, a PT and professor at Creighton University in Omaha. Gail writes the editorial in response to a paper I’ve covered in the Crab before, “An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, or Professional Roles” by Ross et al. It’s a great reference piece and available open access. The reason I’m looking into the editorial, rather than the piece, is that it breaks down complex topics in just 3 pages and gives actionable information and advice on how to address these issues in your own life and practice.

The piece, and this editorial, break the challenges of LGBTQ+ PTs down into three main topics, normativity, stress and labor, and professionalism. Normativity is about the language that frames our lives. According to the editorial, “Understanding the term heteronormativity is foundational to gaining insight into the lived experiences of our community” because of how it permeates culture and our personal assumptions, often “othering” those who fall outside norms. Simple assumptions like a patient’s gender, a partner’s gender, the alignment between gender and gender assignment at birth, all of these are viewed in a heteronormative world and the expression of them can lead others to “turn their light down” and be less authentic versions of themselves.

As anecdata, this has certainly been a factor in my life that has changed in the last few years. It started with simple things like embracing purple as my favorite color, as it always has been, rather than blue because purple wasn’t “manly enough” to me when I was younger and advanced from there. I know it’s simple, but it’s important to me and being in a more supportive environment in life has helped me express that.

I’m rambling, so let’s go to the next section.

Tell Me More - The next discussion is on Stress and Labor, where Jensen discusses our work environment. I think this can be broadened beyond just PT, to our patients as well. According to the Ross paper, “there is a toll arising from the fear people experience when they consider sharing their true identity,” and I’m sure patients go through the same. According to Jensen

Fearless organizations create workplaces where human capacities can flourish in an environment that provides psychological safety. These environments facilitate a sense of trust and respect as all members of the team are free to speak up without the fear of embarrassment or rejection.

This type of organization is helpful for those with non-heterosexual identities but also, in an industry where 47% of therapists experience inappropriate patient sexual behavior each year, this sense of trust and respect in a workplace could help curtail that. There is an innate tension in PT, according to Jensen, where “there is the expectation that (1) we care for all patients, regardless of their behavior, and (2) this caring overrides everything,” potentially even the clinician’s right to be treated with dignity and respect. It shouldn’t but in some workplaces it does, leading to burnout, stress, “feelings of powerlessness, discrimination, and invisibility.”

Lastly, professionalism, which “Ross et al argue… is the pervasiveness of cis/heteronormativity, along with other white middle-class norms that can lead to the perception of being ‘deviant’ and not conforming to what is perceived as professional.” Jensen argues that “for far too long, we have assumed that the conceptions of a profession— developed and shaped by how we see traditional (historically white, male-dominated) professions—are not to be questioned or shaped by other professions, including female-dominated professions.” In Jensen’s understanding, “the ability of our colleagues to bring their diverse characteristics into the workplace is important in connecting better with patients and fostering inclusive workplaces for others.”

I know that none of the above actually gives an actionable step you can take in clinic today to make your practice better. But I hope that it leads you to question the priors and norms inherent in your care and clinic and that you turn up the light of your individualism and help create a safe space for others to do the same.

Paper? Got it.

How Do I Increase Self-Efficacy? The Coach Approach

The Gist - In school, pretty much all of us learned about motivational interviewing and we probably practice it and are probably great at it, but this paper argues that doesn’t go far enough. Especially when trying to increase self-efficacy. In assessing problems beyond simple PT (like obesity, exercise adherence, unhealthy diets, self belief, etc.) these researchers argue that a coach approach is the way. In their minds, PTs should adopt a health coaching approach to facilitate behavior change. In this mindset, the PT assumes that the patient is the expert on their body and experiences, rather than the PT. The PTs role is to discover what the patient wants, how they are being held back, and help the patient come up with strategies to achieve this. The PT is a partner, not a leader. This increases the leadership of the patient in their own process and thus increases their self-efficacy in the task at hand.

For PTs to successfully change paradigms from expert to coach, three key concepts are useful to understand. First, the patient is the expert of his or her own life. Second, providing education is necessary but not sufficient to catalyze behavior change. Finally, the clinician must have an awareness of when the coach approach and when the expert approach is most effective. Facilitating behavior change is within the scope of practice of a PT and is an important part of the professional role of the PT as even small shifts in individuals’ physical activity, dietary patterns, and stress can result in meaningful reductions in disease burden and cost across populations.

Tell Me More - If you’re interested in how this works functionally, they go on to a case study where they break down ways to change from an expert approach to a coach approach by rephrasing sentences and modifying one’s role. It’s really well laid out and I highly recommend you read it. Afterward, they go deep on theoretical models of behavior change, motivational interviewing, and more, so check those out too if you’re interested, it’s just too much to put here. What I will put here is their discussion of positive psychology, the “scientific study of what makes life worth living.”

In contrast to the typical approach of searching out and defining what is wrong, when facilitating behavior change a clinician can choose to shift attention away from pathology and pain, redirecting it toward a patient’s vision of the good life… It seeks to understand what helps people feel positive emotions and focuses on flourishing doing good out of a sense of purpose or calling. Generating positive emotions and connecting them to an individual’s strengths and vision can be counterintuitive for clinicians trained to identify pathology and problems. It requires they shift from following a “trail of tears” to following a “trail of dreams”.

If you find all of this interesting, do please at least skim the paper. It gets into the weeds on psychology a bit, but most is very understandable for all. PTs are in a great position to health coach because of our relationships with our patients, so do consider this approach if it strikes you as possible.

Paper? Sure thing.

Will you do your HEP if you know it makes me sad when you don’t?

The Gist - How do you feel about patient adherence to HEPs? Not, how important are they? But how do you feel? That’s what this group publishing in the Journal of Physiotherapy wanted to know. So they asked. They interviewed 10 UK physiotherapists and focus grouped 8 others to find out. Overall, four themes emerged.

• Adherence is a challenge, but worth working for
• Adherence is frustrating, but you can’t win them all
• Individuals are our patients and they have complex lives that can make it tough
• My job is to help the patient, even with poor adherence

We’ll dig into all of them a bit and I should note, this is a qualitative paper, so there are great quotes throughout if you wanna check it out. To the first theme, the physios stressed that it’s really tough to get adherence, but worth it and that it’s really hard to measure unless it’s 100% or 0%. To the second, they talked about learning how to let it go and how that can be a real challenge. The third theme, many physios discussed that they understand why it doesn’t happen, even if it’s tough. And to the fourth, they really stressed their relationships and the patient goals to get them on board and to help the physios stay engaged with the case.

Tell Me More - I noticed two themes the authors didn’t explicitly discuss as well. Those were the physios learning to be honest with their patients about their own exercise regimens and how those are tough to keep even though they know they need to. “Some patients will say to you ‘I really struggle to do exercise’, but often they won’t ever talk to you about that, unless you bring it up” and “Sometimes the public perception is you love exercise and you find it really easy to exercise and I think patients maybe sometimes worry about saying ‘Well actually I don’t really like exercise’”.

The other theme was the physios learning to let go of adherence as a reflection of their practice.

They did their best to encourage adherence to the exercises they prescribed but also recognized that if patients did not make sufficient effort to adhere to them, they could do no more. Participants described how they learnt this from experience: “Me personally, I’m getting better at saying ‘well, I’ve done my job’ so I don’t take it so personally anymore (P15)”

I know that I’m just one more water drop in the ocean telling you to look out for yourself and don’t burn out, and that burnout is a system problem, not a person problem, but this is a thought process to watch out for to help yourself. If they’re not exercising, it’s probably not you and it’s not a reflection of your practice or worth as a PT. Remember that.

Paper?Gotcha covered.

When Patients Get Inappropriate

The Gist - I probably don’t need to tell you this, but patients can gat inappropriate in clinic. Surprisingly at first, they’re less ina-pro-pro with pelvic health providers, though this paper elucidates that a bit since more experienced clinicians tend to have fewer inappropriate patient contacts and pelvic health practitioners tend to be more experienced. They also tend to work more with women than men which confers a protective effect. 33% of pelvic health PTs had experienced inappropriate patient sexual behavior in the 12 months prior to the survey while 48% of all PTs and SPTs surveyed had.

More experienced PTs also tend to use the more effective mitigation strategies of directly addressing the behavior. The survey found that the most successful mitigation strategies included

Distracting or redirecting the patient, choosing more public treatment areas or treatments with less physical contact, speaking directly to the patient about their behavior, behavioral contracts or modification plans, transfer of care to another PT, and chaperone use at subsequent visits. Experienced clinicians were more likely to be direct, while novice clinicians were more likely to engage in the unsuccessful actions of ignoring and joking.

It’s unclear what leads less experienced PTs to experience more inappropriate behavior, but 58% of SPTs and SPTAs experienced it in the last 12 months compared to 42% of the professionals. We can speculate on this, but I think it’s even more important to add this to PT curricula since it’s not really there already. We talked about this a tiny bit in my program, but not enough, did you in yours?

Tell Me More - I know you know this is serious stuff, but it’s extra serious. 15-30% of people subjected to inappropriate behavior report burnout, absenteeism, and resignation in its wake. 25-50% of all professionals who encounter it experience anger, guilt, fear, anxiety, and depression. So how do we prevent it? Surprisingly, chaperone use during pelvic health work didn’t affect the prevalence of inappropriate behavior. And that’s kind of all we know. This was a survey, so there’s not a lot in that regard. The authors do discuss it though:

At the very least, information on the likelihood of encountering such behaviors and offering strategies to address the behaviors would be prudent. Perhaps, with additional research on risks in working with this patient population best practices can be tailored to these specific situations. Knowledge is power and empowerment is a means of prevention. No practitioner should have to weigh safety or mental health concerns against working in a practice they are passionate about.

Male therapists are far from immune from inappropriate behavior, but it does seem to be a protective element. “ Women were more than twice as likely as men to have experienced IPSB (inappropriate patient sexual behavior), and clinicians who treated mostly male patients had almost a 400% greater chance of exposure to IPSB.”

Do you have any tactics or steps that would help prevent this from occurring? If so, let me know and I can distribute them to more people.

Paper? Got it.

Thanks all, that’s the week! Next week things should look and feel different, but not be different.

’Til then, bye!