Three roads home

[Barrett Dorko]

It’s been a quiet week in Cuyahoga Falls…

Each day I see a variety of patients. Most are older than I but no more than my parents were. We have the things in common that each adjacent generation might; world events, music, books, TV shows, movies and styles. I feel that I’m perfectly positioned to draw from each patient some story that will expand upon what I knew as a child and what they observed as an adult. Almost without exception their stories are different in a way that teaches me something about our common experience.

I hope you notice that the subjects I choose aren’t about me – they’re about us, and they’re about the world we have both occupied and still do. I’ve always done this and during the past year I’ve discovered that this sort of communication is rare in the therapy department.

What I see instead is this: a therapist will begin to talk about something completely self-referential and then expand upon that. Their difficult drive to work, their kids, their own illness (I’m not kidding), their hobbies, their personal relationships, and all of this, it appears, is completely disconnected from the patient or the problem at hand. The therapist will occasionally interrupt themselves to direct a movement or count out yet another set of essentially useless but reimbursable exercises and then rapidly return to the small talk that passes for “getting along” with the patients. “My patients love me” is what I’ve heard from many who do this.

This manner of communication has its close cousins. Sometimes the therapist will get the patients to speak similarly. The worst, I think, is when two or more therapists do this continuously among themselves while the patients are obliged to listen as if potted plants. This makes my blood run cold.

The word trivia has its root in the Latin meaning “three roads.” My understanding is that Roman soldiers would post messages on posts erected where three roads met, knowing that someone traveling along would carry them somewhere else, and on and on. Since all roads led to Rome (supposedly) they could get their messages home. This means that trivia wasn’t something small; it was deeply rooted in the culture’s communication, both personal and universal.

Given an opportunity, I will often engage my patients in trivial knowledge. It might be about who played what part in which movie or what sports stars they remember from the local teams. I might find that they read a lot and I can begin a conversation there. I try to find something about their passions and use that. Eventually, I relate what we’ve spoken of to their therapy somehow. I don’t usually know how that will happen until I hear myself speaking of it.

This isn’t small talk, and it’s not about me. It implies that I want to connect their life to the fix they find themselves in and carry the message to another place, closer to home.

What do you do?

[nari]

These therapists sound like hairdressers. Perhaps that is all that is happening: patient sits or semi-reclines, body dresser does what is required (or not) including chit-chat and gets paid for it.
Could be done by anyone and at much less cost.
Amazing.....

Nari

[Barrett Dorko]

Nari,

Insightful. The sense I get is that this is what the staff wants.

[nari]

That would appear to be the case. Sad for the profession, but true.

Nari

[Jason Silvernail]

It's a testament to how little people are thinking about what they are doing when their actions become so robotic they actually long to occupy their minds with *something* while doing their jobs. Their first choice appears to be self-referential small talk. Great.

I continuously correct this when I see it in the clinic.

[Barrett Dorko]

Jason,

I think you're right. For all we know, zombies are thinking about what they cooked for dinner last night, what their kids are up to, their pets and hobbies, their last (or next) text message, their crappy hair or how their arms ache from that posture they've been forced to adopt. Of course, zombies don't speak so this is pure speculation.

I can imagine someone I work beside reading this and objecting rather vehemently. "I'm not a zombie!" would be pretty much the gist. To this I say, "I'm sorry that you feel I was talking about you. All you have to do is demonstrate how you've changed your approach on the basis of some education during the past six months and I'll abandon my default mode and assume you have some passion for the work. What have you read lately? How is that specifically related to a patient you're seeing today? What have we learned about the nature of the nervous system that can transform our handling and manner when dealing wih a patient in pain? If you've nothing significant to say I'll simply conclude that you aren't a bad person, but that you practice robotically and thoughtlessly. Rather like a, well, you know. We both know that you act like a hairdresser."

Of course, I never say any of this where I work. As a contract guy on a very short leash I have no standing and anything I say may jeopardize my living. In effect, I'm in much the same position as some of the students here.

[Barrett Dorko]

I spoke to someone interested in my writing about this hairdresser thing and she said, "Well, if that's what the patients want (in the way of atmosphere) then I guess it's okay."

She's right in a sense. If the patients don't complain then why should I? But I'm not of the opinion that the atmosphere in the therapy department should to be determined by the patient. Isn't it the therapist's job to understand what it should be? Shouldn't they control the noise level, the "sound design" and the nature of the conversation so that recovery is brought to the forefront?

After all, therapy isn't about looking better so that you'll feel better about yourself - it encompasses so much more than that.

I envy Jason's authority.

[John W]

I continuously correct this when I see it in the clinic.

I've made several direct and indirect references to the clinic director about the often loud and, now that I think about it, self-referential banter that goes on in the clinic. He seems to abhor this as much as I do. But I've yet to see him confront anyone about it, and it certainly hasn't lessened in frequency or decibel level.

I suppose as long as patients keep coming back and a modicum of rapport is maintained, then it's not really seen as an issue that needs addressing. As the clinic director is often overwhelmed with the herculean effort of dealing with a fundamentally flawed and increasingly stingy reimbursement system, the last thing on his/her mind is mindless clinic banter.

Just the same, it's sometimes all I can do to refrain from saying, "Enough about your damn kids, already!"

[Barrett Dorko]

Perhaps Jason can tell us how he does this without offending anyone. Maybe offense isn't as large a consideration in his position.

John,

I can understand why the guy in charge doesn't say anything, given his responsibilities otherwise, but why isn't there any discussion about this issue among the staff?

Maybe you could do something on "sound design" and introduce the subject in this way.

[Bas Asselbergs]

Just a thought about the boss NOT saying anything;

unlike Jason, who works in an environment (I assume) where authority and constructive criticism is much more a given, the workplace for PTs seems to be a "let's all be gentle and caring and non-confrontational" type of setting. The banter is the PTs ONLY way to add some enjoyment to their plodding day of regurgitating crap, with no end in sight.
The boss will not want to upset the cart, because s/he too feels the despair of their rut.

Needless to say, it would only take a simple but brave step to change that - a visit here for instance, or some reading, or self-reflection....

"Shut the F**K up" is something that may not work well now, but it would certainly come to MY mind.

[John W]

You're right, Bas. Everyone deals with ennui differently. Some people stew in it, some people try to take their minds off of it my listening to themselves talk. In either case, the focus is certainly not on the patient.

So, the banter is just another symptom of a constrained mind.

It'd be interesting, though, to address this in a professional staff meeting, which our clinic hasn't had in about 3 months due to everyone's conflicting and busy schedules. I wonder where a conversation about the "sound design" might lead? I suspect it would likely come back to what the elements of a therapeutic encounter should be. Uh oh...

Barrett, I should know this, but have you written an essay that addresses the elements of the therapeutic environment such as this? That might be something I could send to the staff as a way to prime them for a discussion about the noisome noise.

[Barrett Dorko]

John,

I appreciate the question. I don't think I've written anything all that specific, but The Chair comes to mind.

This piece is more metaphorical than directive, but the design of any department must look continually toward a set of principles agreed upon by the staff. It would be a good idea for the director to articulate those principles. I don't work with any directors like that currently.

Maybe Jason will find me a job in Texas. I'd work for him any day.

[Jon Newman]

I feel that I’m perfectly positioned to draw from each patient some story that will expand upon what I knew as a child and what they observed as an adult. Almost without exception their stories are different in a way that teaches me something about our common experience.

I hope you notice that the subjects I choose aren’t about me – they’re about us, and they’re about the world we have both occupied and still do.

What do you do? --Barrett

I honestly try to do the same thing. Unfortunately, I've discovered that my repertoire of trivia could use some work (more TV maybe). Or perhaps it's just my inability to express it in a helpful manner.

[Aspiringphysio]

The way you wrote this makes it sound like the therapist talking about themselves to patients is normal? You are allowed to talk about your own life to that degree? I thought that was a big no-no? Or at least here it is...

We talk about current sports matches (a bit of friendly rivalry if you support oposing teams), TV programs, I was working in a comunity MS placement 3 mornings a week for one of my recent placements and my patient (she was mine for the 3 weeks I was placed there) was into the Dancing with the Stars programme. So I would make sure I watched the episodes each week so we could discuss them during her sessions. She was a very quiet reserved lady and this was how I formed a connection with her as well as talking about cooking too lol.

We often talk about the weather since its been pretty extreme here recently and basically latch on to the hobbies and social things they have told us about.
As we are students, quite often we get asked about upcoming exams and what we are learning in classes etc but we dont talk about our personal life.

I'm not much of a small talker myself so I quite like the silent pauses that happen during my 'time' with patients, other times I tend to be trying to explain what I'm supposed to be doing and how I understand what its supposed to be achieving (more so for myself I guess).

On my last placement (in the hospital outpatient clinic), one of my classmates made a remark during his subjective taking that he was also feeling some back pain himself so knew what it was like and how bad it can be (the patient was in for chronic low back pain...) and our clinical educator said that we must try and remember not to do that in front of patients, that its not professional to talk about ourselves. I know I am very careful not to say anything that suggests I live with pain, despite sometimes feeling like it would add credibility to what I am trying to explain.

I even got had up about the way I was sitting and how unprofessional it was. Maybe they are just stricter here or we have different rules? I just find it really facinating that you are breaking professional boundaries by making it so personal or have I missunderstood this a little?

[nari]

Felicia, it is the same in Australia re the issue of personal stories.
It is automatically assumed that a professional never talks about their personal life to patients, and I have never heard any PT do so.
It is simply..well, inappropriate.
If a PT comes to work with a sprained ankle or some visible injury, it is spoken of briefly, with humour, and the focus switched to the patient's problems.
I've even been to hairdressers who never discuss their personal issues.

Nari