In my 9 years as a physical therapist, I have found that my relationship with patients matters just as much as the actual skilled physical therapy care that I provide. In my training, whether in PT school, or taking long term courses, very little time was spent on how to best foster my relationships with patients.
As PTs, it is not necessarily our job to be psychotherapists; however, since we deal with people, we deal with their emotions. In my practice, I am still working on how I interact with patients (especially difficult ones). Through working with different people and different personality types, I have developed some strategies, and would love to share them with new grad PTs - especially since I wish that someone had shared them with me. I have come up with 6 strategies to help deal with difficult patients.
1) Realize that it's not you, it's them
While your patient may be saying a lot of things to you, realize that what they are saying is a reflection of themselves, and has very little to do with you. When the patient woefully says things like, "I thought that PT would have worked by now," try not to take it personally.
When you are working with a patient in PT, you are only experiencing one aspect of their lives. Unless the patient tells you explicitly about other aspects of their lives, you don’t know what their life is like once they leave the clinic. Maybe they are having problems at home, or at work. The pain from the injury that they have may also affect the patient's mood.
Even if patients do tell you about stressors in their lives, it's important that you recognize that this may impact how much of their time and energy they can devote to PT, as well as their pain levels. Emotional stress can have an impact on pain levels, and while we may not be able to treat our patients' emotional stress, we can at least acknowledge it.
2) You are not responsible for patients' successes and failures
While we all want to think that we are responsible when our patients succeed, and stand there proudly while they demonstrate their newly achieved mobility with tears of joy in their eyes, this is a double edged sword. By being responsible for their successes, it means we are also responsible for their failures.
As outlined above, there are aspects of our patients' lives that we have no control over, which may be affecting their outcomes. If you take responsibility for your patients' successes and failures, then you are taking responsibility for a lot of things that you have no control over. If you do this, I can guarantee that you will burn out quickly.
I used to be mentored by a wise old PT who said, “My goal is to lead you on a path to self discovery.” He would say it to me, and he would say it to patients. As physical therapists, we are guides, we are teachers, and we are facilitators.
3) Ask lots of questions
When a patient states, “I thought that PT would have worked by now,” ask them why. The patient may say something such as they got better faster the last time they saw a PT for their injury. If this is the case, follow up. Ask them:
- What did they do in PT?
- What was their previous injury?
- Did they do their exercises regularly?
Ask them the "whys" of how they feel until you get some specific answers. Once you have specifics, you can address them. Maybe the patient didn’t have time to do his or her exercises this time around. If you ask why, and find out that they had work, then had to pick up their kids, and make dinner, etc., that's important information for you. From there you can try to modify their home exercise program in favor of exercises that require minimal setup and equipment, or that do not have to be done all together, or all at once.
You may also then gain some insights into other facets of their lives they they would not have shared with you, if you had never asked. Additionally, as you question the patient, they may also gain a better understanding of what their limitations are with PT. For example, some people may not realize how busy and impacted their schedules are until they are describing what they did the other day.
4) Be firm
If your patient continually shows up late, and then proceeds to dominate your discussion with them talking about topics that are not related to PT, or their injury, then you need to put your foot down. If your clinic has policies regarding late patients or no shows, then you should enact those policies.
Your time is valuable, and for every patient who does not show up for an appointment, or is late - causing you to be late with your next patient - they are taking away resources from others. For the patient who is routinely 10-15 minutes late, you may say something such as, “I have noticed that you continually show up 10 minutes late. When you are late, it is difficult for me to provide the care that you need. Additionally when we run over our appointment time, my next patient is left waiting.”
If your clinic has a policy where you won’t see patients who are more than 15 minutes late, use it. If not, you may consider explaining to the patient what happens when they are late and suggest that they try to find an appointment time that works better with their schedule.
As for the patient who dominates the discussion with topics other than PT (or starts to cry), let them talk about whatever they want (or cry), for a minute or two. Acknowledge their feelings, or hand them a tissue if they are crying (you may want to have some handy in your treatment area). Then redirect the conversation.
You may feel as though you are cutting the patient off, but the patient is there to learn from you in a short amount of time. If you are not able to get your message through to them, then you are not helping them. If a patient takes control of their appointment by running late, and dominating the discussion, it will be more difficult for you to help them. If you continually allow patients to control your session with them, you may not be able to provide the patient with the care they need.
5) Do not let patients verbally abuse you
I used to treat a very large male patient, who would curse a lot during our sessions. While I knew that his cuss-filled rants were not directed towards me, they often left me feeling on edge during our sessions. I typically would treat patients out of a private treatment room in our clinic, but had decided to start treating this patient on a treatment mat in our open gym area. While he would still curse at times while we were working in the gym, he would not curse as much, or as loudly when we were working in the gym. I felt better, because the patient had toned down his volume and his language.
If a patient makes you feel unsafe (if you are not sure if a patient makes you feel unsafe, if you are thinking that they may make you feel unsafe - then they probably do), you need to do something about it. Use the resources available to you to protect yourself. Ask a colleague if they can co-treat the patient with you, ask a colleague if they can take over care, treat the patient in an open area, or talk to your supervisor. If you are fearful, and not comfortable while treating patients, then you're not likely to provide your best care.
6) Address the elephant in the room
Once you have identified that patient who is experiencing some emotional stress, may not be ready to make lifestyle changes allowing them to be successful in PT, or whose behavior leaves you on edge, you need to let the patient know that these behaviors may also impact their recovery.
To the person who has stressors in his or her life, you may want to saw something such as, “Wow, it sounds like you have a lot of stressful things going on in your life. While I can help you to recover physically, please know that your emotions and stress can impact your pain levels or motivation for attending PT.” From there, you may ask if the patient has someone that they can talk to regarding their stressors or emotions, whether it is a psychologist, social worker, clergy member, trusted family member, or friend.
For the verbally aggressive patient, you may say something such as, “You seem angry. When you curse, yell, etc, I find it difficult to provide the care that you need.” Again, you need to be clear about what you can and cannot provide in PT. You can help patients to physically get better, but they need to be emotionally present and ready for PT.
As physical therapists, we do deal with different personalities and different emotions. Part of successfully working with patients (whether success is patient outcomes, or your longevity in the profession) is knowing the limitations of what you can provide. You can guide the patient to get stronger, become more flexible, learn good lifestyle habits, and understand good movement patterns.
Physical therapy is not something that you do to people. Physical therapy is something where the participant is involved and engaged in their recovery. You are simply a guide.