Language is defined by Merriam-Webster as:
1a : the words, their pronunciation, and the methods of combining them used and understood by a community
1b : audible, articulate, meaningful sound as produced by the action of the vocal organs
(2) : a systematic means of communicating ideas or feelings by the use of conventionalized signs, sounds, gestures, or marks having understood meanings
(3) : the suggestion by objects, actions, or conditions of associated ideas or feelings
This is an important concept to remember when you work in a clinical setting. I really like the second description as it discusses the idea of communicating ideas and feelings through conventionalized means. I want you to really focus as I take you through this blog. Think long and hard about how you, as a clinician, present information to a person who perceives you as someone with power and knowledge. This underlying assumption by the patient sets the entire tone for your future relationship with them.
My formal training is in chiropractic. Looking back on my education, I feel there could have been more done to address the psychology of patient care. We had one clinical psychology course. It was a great course, but you could spend the entire time you are in school learning the power of language and its effect on patients. This is particularly true of professions that utilize the power of imaging to communicate.
Take a long hard look at the next four images. I randomly grabbed four pictures of MRIs of the lumbar spine from the internet:
Many of you are likely in a profession that utilizes imaging when working with patients. Images are powerful tools to have a discussion with a person about a possible diagnosis when they are seeking your services to try and solve a problem. You can use the images you obtain for a couple of different reasons. Before we move forward, I want to make something very clear to you. I have said nothing about the particular diagnoses in any of these images. I have said nothing about if the person who had these images taken of their lumbar spine was even having any symptoms. This will be very important to keep in mind as we continue this discussion.
It is hard to read this picture because I got it from a friend who was at a national physical therapy conference. I will explain what is going on in the graph below.
This graph shows what percent of people would be willing to have surgery if an MRI or x-ray showed an "abnormality," even in the complete absence of symptoms. I found the number of people who said yes to be staggeringly high. This is even with the understanding, as shown in the graph on the far right, that surgery is by far the most risky. The results here are disturbing at best, but give us some insight into the current culture surrounding clinical work, imaging, and communicating with patients.
Let's take a look at another recent example of imaging and patient care. This is from a physical therapist named Tony Comella.
There is a lot to sort through here. It is another stark reminder of the power you have as a clinician when you are standing in front of a patient with an image. Just look at the numbers. These are all from interpretations of images for people who were 100% asymptomatic. That is an important piece of information to remember. Here we have thousands of people with significant structural damage, as seen on an MRI, with zero perceived problems.
I am not going to tell you imaging isn't useful. It is. It is useful when the history a person is giving you is lining up with any assessments and other examinations you may want to do that lead you to the conclusion an image is necessary for you to have a complete understanding of what is going on and will help you decide a course of action with some certainty. It can also be a valuable tool for explaining to a patient that something they are experiencing may or may not be correlated with what is seen on an image. Pain (the symptom someone is most likely seeking your services for) is a funny thing. It has so many ways it can manifest itself and so much of a person's life is tied to how they experience it. That discussion can fill ten more blog posts. Just understand it is rare what you see on an image is directly related to pain. This leads us to the next part.
Why are you using the image and what kind of language are you using with the patient to explain what you see on the image. Think critically here. Are you using the image to help a person gain a clearer understanding of your best diagnosis given all the information you have and to use that information to guide them through a plan that steers them towards independence from your care? Are you using the image to create fear in the patient and orchestrate a scenario where you convince them the only way to get better is if they sign on for a long care package with you that sets them up for dependence on your care? You have all the power here. Remember, an image is just a piece of information. You rarely can draw any conclusions of certainty about what you see on an image and the experience of the patient (unless there is a clear fracture or dislocation or something of that nature). At best the information is correlative. People will become their diagnosis if you speak to them in a way that leads them in that direction.
This is where treating with a prognosis (a forecast of the likely course of a disease or ailment) in mind is more valuable than a diagnosis. You have to be very careful here when presenting a person with all the information. You set the tone for their entire recovery with your language. That may sound bold, but there is a lot of truth to that statement. Some people will never get better no matter how you talk to them. There are some people out there who are searching for totally dependent care because they refuse to believe they have any control over their current situation. These people will suck the life out of you, so be very careful. Getting back to prognosis, you have to learn to use all the information you have and then have an open and honest discussion with the patient about the probability of them improving and how you can work together with them to help them solve the problem; mostly on their own. I know you went to school to learn all sorts of different ways to do the same thing to people, but manual therapy has marginal benefit at best (and typically only in the beginning of care). Much of that work can be performed by the patient when they are not in your clinic if you are comfortable teaching them. You have to be confident enough to realize the patient is more likely to seek your guidance in the future if they feel like you are helping them solve the issue and you are able to give them useful tools that move them in the right direction. You also have to be comfortable telling someone their problem may never resolve 100% and at best we can optimize the overall quality of their day to day life and overall function. You will realize people are much more likely to respect honesty than find out later you used your power, language, and information to talk them into something they didn't need.
I also understand that running a clinic is a business. You have to make money to put food on the table and pay your student loans. You have to become good at selling, but not the way you may be thinking about selling. I know all sorts of weekend courses you can go to that teach you to manipulate a person with your language so they will sign up for lots of stuff they may or may not need. I am talking about selling people on the idea you know how to help them help themselves. That is much more powerful in the long run.
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