Things They Don't Teach You in PT School

We tend to have a lot of students in our clinic. High school and college kids doing observation hours or volunteering, athletic training students, and physical therapy students. We also get the occasional medical student or resident. There are always students around and it's a pleasure most of the time. As our AT and PT students are going through their curriculum and learning how to help people, they are learning techniques, exercises and reading research. Therapeutic alliance and troubleshooting usually fall in the gray area between the clinic and the classroom and are often times overlooked. I usually give them some articles to read through and one of my favorites for students is an article by O'Keefe et al, published in Physical Therapy Journal in 2016. The authors review what factors play a role in patient-therapist interactions in physical therapy. This article has been really influential for me in my practice in both creating a good therapeutic alliance and also in helping patients get on the right track when their road hasn't been a smooth one. I want to give a brief overview of the points that really hit home for me from this article.

The authors determined four themes with identifying characteristics under each theme. I'll add my two cents relating to how I try to practice after each characteristic.

Theme #1: Physical Therapist Interpersonal and Communication Skills

Active Listening: Every time I have a new patient, I feel like I should have written down more details - but at the same time, I think it's an important time to make sure I'm getting the right story, goals, motivating factors, etc that you gain from just listening.

Empathy: I really try my best to put myself in the shoes of the patient. Things that are frustrating for them, might not be to me personally, but you have to understand where they're at to be able to help them get to where they want to go.

Friendliness: I almost always try to get some sort of laugh out of my patient in the first five minutes, no matter how stupid it may be. I have been trying to ask about their day, BEFORE asking how the shoulder, knee, etc is doing.

Encouragement: The more you practice, the better you'll get at recognizing when your patients need some encouragement. It's easy to see when a patient is on their last set of a BFR exercise, they obviously need a little encouragement at that point, but there are times when it's not nearly as easy to see. Experience helps!

Confidence: Early in your career, it's hard to be confident, you don't have those "auto phrases" in your head for how you like to explain pain, certain diagnoses, or certain exercises. Every discussion makes you feel like you're stumbling through everything. I would say early in your career transparency can be substituted here, as patients really appreciate this, no matter how long you've been a PT.

Nonverbal Communication: I still catch myself with not great nonverbals in certain situations. It's just comfortable for me to stand with my arms crossed, but I need to remember that's not always best depending on the conversation. I almost always try to sit down when discussing something with a patient. Still, there are situations where I prefer to stand too. Mirroring your patient is also something that can help with buy in during tough discussions as well.

Theme #2: Physical Therapist Practical Skills

Patient Education: PRACTICE. You have to develop those "auto phrases" for common things you work with. Now, you still need to individualize them for each patient and each situation. Just the other day, I tried some new patient education points on my wife, so big thanks to her for that. Find people around you, that will help you out and give you some feedback.

Physical Therapist Expertise and Training: No substitute here. You just have to do the work and earn it. I hate the phrase "fake it 'til you make it." It's crap. Just "make it" as quickly as you can. You'll have certain diagnoses and types of patients you work well with, knock those out of the park! Also, don't be afraid to tell patients about your training and education if they ask. I don't run around telling everyone I'm a doctor of physical therapy, but when they ask where I went to school or how long I went to school, I mention that it was 3 years after my undergrad to get my doctorate in physical therapy. "I didn't know PTs have a doctorate degree!" This is a great place to start a conversation and educate your patients about physical therapy.

Theme #3: Individualized Patient-Centered Care

Individualized: I have certain exercises I like to use for certain patients and diagnoses. I see quite a bit of the same diagnoses, so I have a saved bunch of exercises for those cases. I'm always marking them up a little bit differently for each patient. You have to put that "stamp" on it. It has to be specific to them. This helps with patient engagement and buy in - which really helps with helping them to get where they want to go.

Taking Patient Opinion and Preference into Consideration: I really do my best to try to get my patients to feel comfortable asking questions. I want them to get the most out of their physical therapy! Again, this helps with patient engagement and buy in. If I'm seeing someone on a "second look" I'll always ask about their previous PT visits - what things worked and what things didn't. There's no sense in doing things the patient doesn't think will help. Conversely, if they felt like something helped - then I'm going to incorporate that into our treatment plan for sure.

Theme #4: Organizational and Environmental Factors

Time: I really do my best to never seem rushed when I'm with a patient, no matter how far behind I might be. If I'm juggling two at once for a brief time, I actually move slower, because I don't want patients to feel as though I'm rushing through their visit. Also, sometimes a patient just wants to BS with you for a few minutes after the visit is done, or a parent might have a few questions after a session, again - take your time!

Flexibility with Patient Appointments and Care: There are certain times I'll make myself more available for certain patients. If I have a patient come in and they are the type of patient I'd like to see more of, those are the ones I'll bend a little more for. If I'm "squeezing in" someone in a time that doesn't really exist, I let them know that. I don't want them to be surprised if it's a shorter session than usual for them. The more patients out there with good stories about physical therapy, the better.

I think a lot of these traits and themes become really important when you are working with patients that have a long history of pain or have tried everything else or have had a lot of physical therapy in the past but are a new patient to you. These types of patients can be a little more challenging, but who doesn't pride themselves on helping these types of patients reach their goals? Nevertheless, taking some extra time to focus on some of these things with all of your patients will help both you and them. Go ahead and take some of these things into the clinic and let me know what you think. Do you have anything to add?

Brett