In walks your 2pm evaluation. Well, not really...they scoot in backwards, sitting on their four-wheeled walker complaining about how long the medical history form is and "why do you need to know all that stuff?" A long past medical history is fine, you can handle that, you can synthesize how 10 years of uncontrolled diabetes mixes with COPD, a back problem they've had "since they were 19" and the multiple progressive knee scopes and procedures they've had.
During the interaction, however, the person is "off." They don't interact with the ease and simplicity that you do with your staff, your friends or the prior patient. You can't quite describe it well. They don't pause in sentences when other's do, their train-of-thought derails and it's hard to keep the subjective portion on task. Their life experiences are such that you don't want to ask any more about them because it's awkward to be sitting in front of someone who has lived through stuff that writers write in to movies to make the film intense. There is depression, anxiety, poor social skills, hard times, bad relationships, disabled from work for 15 years, no helpful neighbors, family that that is around but won't help due to reasons you are not asking about. You suspect a variant, or at least somewhere on the continuum, of a mental disorder, but not at a clinical level. Poor social and reasoning skills have lead to poor choices and habits now so deeply ingrained that you could not unravel them from the person even if you thought that would help.
And here is the problem. You do think this would help. You see the potential. You see how "if they could get their act together" if they could go to the gym that their insurance is paying for, if their views about health would change perhaps they could get ahead. Perhaps if they could be shown that working at something pays off they could get back in the work force, have a reason to get out of the house and get out of that bad neighborhood. You see all these modifiable factors (in your mind) that would benefit this patient... yes along with the Range of Motion drills and gradual progressive exercise for the knee, hip and ankle (and tight hamstrings *wink*).
You lament after each session about progress. You start to blame the patient because your treatments are not helping... or they would help if it weren't for the fact that your patient is "so complicated." If they could actually call their primary care MD (like you said to do) and ask about options instead of Percocet, or make amends with their sister who could then drive them to work and they would not have to walk to the bus stop 1/4 mile and bother that Left knee so much. If they weren't so manic when you're asking questions about their condition they would actually remember some of the advice and patient education you gave them.
You must remember: This is the person you are trying to help.
...with all of their traits. Treat that person.
You don't get to pick their biology, their psychology, their social factors. You don't get to pick their coping strategies, their behaviors, their barriers. This is the person you are trying to help. Treat them at face value.
If it helps you mentally you can note these items as "barriers to progress," but after you do... you need to help this person. With all their individualism, abilities, goals, limitations, barriers. Help coach them in all these areas, as best you can, knowing these peri-injury factors can make a big difference.
I speak this phrase often both to myself at the end of long days in the clinic, and to other providers who are starting to vent. In many cases these "complicated" people can frustrate providers because we see the potential... if they would just change. So to avoid the gossip, avoid the staff complaining, avoid the empathy burnout, try to restate the mantra: "This is the person I'm trying to help."
and then off you go....
-Matt Dancigers, DPT
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