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The Four Laws of Quality Care, Law III
Welcome to the third installment of this four-part series on The Four Laws of Quality Care. These Four Laws include the foundation of everything that I’ve come to learn in my career thus far.
Law I states: Rapport is the most important thing. Period.
Law II discusses the exam process and states: Transparently investigate their primary concern, including symptom modification whenever possible.
Here we’re talking about the Third Law of Quality Care: Help them make sense of their problem.
In this article, we’ll discuss,
The importance of helping people make sense of their problem
Things that get in the way of effectively educating our patients
Ways of overcoming these barriers
& How to do all of this within a patient-centered care model.
The Importance of helping people make sense of their problem
Treatment adherence/compliance.
If the person’s problem doesn’t make sense, the rationale of the treatments won’t make much sense, they likely won’t follow the plan, nor can they participate much in the development of the plan.
It’s also important for us to realize that we simply can’t do it on our own.
Everyone’s lives are complicated and include a wide diversity of contexts. We cannot possibly inform people about the infinite number of ways they should manage this problem in their lives (this is especially true for people with longstanding or persistent problems).
When the person’s problem makes sense to them, they can apply the information we give them to the diverse contexts of their life.
If we really want to help people, we need to teach them how to reason and problem-solve.
There are many people who have pain or other problems who never come to PT because they figure it out on their own. They pay attention to their symptoms and what makes them better/worse, modify their activities based on this information, confront their symptoms in a way that doesn’t make them significantly worse, and their bodies do what bodies do—heal—and the symptoms improve!
But the people who come and see us (specifically those who haven’t had surgery or significant injury) come in large part because they can’t figure it out on their own.
I believe this is one of the highest services we can provide for our patients.
Understanding reduces anxiety.
When things don’t make sense or are uncertain, it makes us uneasy. And when we’re feeling anxious, uncertain, or uneasy, it can be difficult to commit to taking action and confronting the problem.
Helping our patients come to an understanding of their problem can help them feel more settled and can increase their readiness to do just that.
Sidebar:
Before we get into the how-to process, I think it’s worth a short mention about my current beliefs about well… beliefs, just so you know where I’m coming from.
There’s a lot of discussions these days about changing people’s beliefs as well as techniques and strategies aimed at doing so.
It’s very important to keep in mind the universal truth in psychology that the only person we can change is ourselves.
We cannot (nor should we try to) impose change on someone. It’s their life, not ours.
And their beliefs are not for us to judge whether they’re right or wrong—who are we to say what’s right or wrong anyway? Science is far from definitive in most things, and our understanding of pain and the human body is certainly no exception.
So what can we do in this space of beliefs?
We can work with the person to see if there’s another way of seeing or understanding things that's more helpful for them.
This might look like:
Discovering what help they are seeking, and how they hope that we can help
Providing help that they’re asking for
Pointing out where their behaviors might not line up with their values and goals
In summary: we cannot (nor should we attempt to) change people’s beliefs. We can work with them to help them come to an understanding of their problem that is more helpful for them.
The big difference here is one of cooperation vs. imposition.
How & Why We Fall Short When Educating Our Patients
Let’s first discuss some common ways that we might fall short when educating our patients that I’ve noticed in myself and in those that I’ve mentored.
The way I see it, there are three distinct phases of education.
We’ll talk through the pitfalls for each phase:
1. Pre-education phase
Pitfall: Failing to explore the person's current understanding and concerns
Pitfall: Failing to explore what the person doesn’t understand or wants to know
2. Education phase
Pitfall: Providing overly lengthy or technical explanations
Pitfall: Failing to provide evidence to support explanations (this is the concept of ‘proving it’ that we talked about in Law II—go check that one out if you haven’t already)
3. Post-education phase
Pitfall: Failing to ask the person for their understanding of what we just said, and how they might apply the information to their problem
And let me just say that I fall into every one of these traps on the reg. So, being the nerd I am, I spend a lot of time thinking about why this might be happening.
When I reflect on the reasons that I fall into these traps, two main reasons come up: ego and excitement.
You see, I’ve spent a lot of time, money, and energy on this PT thing. And I want to be valued and respected as a professional. I want my patients to know how smart I am. And I have a bit of a need for them to see things my way. So by holding fast to my PT role and imposing my beliefs on them in the form of lecture-style technical jargon, I show them how smart I am. So that they will see things my way. That’s the ego reason.
Equally at play is my excitement. I’m a bona fide PT nerd. I love this shit. So any chance I get to explain what I think is going on, the associated theories, the relevant research, I pounce! This ultimately ends up in a riveting lecture for me—I’m on another planet, and I’m having a great time. But then at some point, I come back to earth and I see a bored and bewildered person in front of me. "Shit! I did it again! Better luck next time…"
Of course, as I've been aware of this and working on it, these tendencies have softened a bit, but it’s an ongoing job to not fall back into this stuff—and of course, I still do. We’re all human.
If you’re a mindset nerd like me, this might be where your focus lies—doing the work to relax these tendencies, based on what you notice in yourself.
But I know I’m mostly talking to PTs who want the practical steps—the action items—so let’s talk through some strategies that can help us be a bit more effective in this sense-making process.
The 4 Steps of Effective Patient Education
I’ve broken down effective patient education into 4 steps:
Orienting
Validating
Providing
Eliciting
Let’s dive into these one at a time:
1. Orienting
This means getting a sense of the basics—the lay of the land. Getting a really clear sense of where the person is right now.
Questions you might ask yourself include:
What is this person concerned about?
Are they concerned that something dangerous is going on?
Are they concerned about the diagnosis that was given to them? What’s concerning about the diagnosis? Is it the future implications? Surgery?
What do they want to know?
What do they already know?
2. Validating
This involves acknowledging their concerns and emotions. We see a lot of people who are suffering greatly and are very fearful. And sometimes that comes out in different ways: anger, frustration, sadness, anxiety.
When we let people know that we hear them, it can make a tremendous difference in feelings of safety and trust.
There’s a saying that I learned from a rehab psychologist during a course I took in residency. He said, “If a person doesn’t feel heard, they will get louder so that you hear them.” This doesn’t necessarily mean their speech volume; it may come out in a variety of ways.
The importance is in realizing that people need to feel heard, and acknowledging and validating their concerns and emotions is a key way of doing this.
3. Providing
This is the phase where we provide information. Specifically, this involves providing targeted information, which is:
Framed around their primary concern. Remember, it’s not their symptoms that brought them in; it’s their concerns about their symptoms that brought them in. If we can keep their concerns in the forefront of our mind, and relate our explanations to that, our conversations will be much easier. Instead of talking about the asymptomatic prevalence of OA, we can more directly address their concerns about surgery by talking about other patients we’ve had in the past with the same diagnosis who have gotten better and didn’t need surgery.
Based on information that they already know, want to know, and information that we’ve gathered so far in the exam/treatment process. This is the process of weaving together their prior knowledge, current questions, and exam findings to paint a new picture; one that is more helpful and empowering for them.
In small doses, avoiding jargon. A great way to get someone to check out is to talk too much or use language that is over their head. There's a wonderful quote from Einstein that says, "If you can't explain it simply, you don't understand it well enough.”
With the acknowledgment/attitude that what they do with the information is up to them. It is well within their rights to disagree with our take. And let’s be honest, we don’t know everything. The human body and mind are unimaginably complex, so it’s best to rest in some humility in our discussions with people about their bodies. I find that the more choice I give people, the more open they are to seeing things from different perspectives. Ain’t that the truth for all of us?
4. Eliciting
This involves asking the person for their thoughts, interpretations, and applications of the information you just provided.
This asks the person to make use of the information. This is important because information alone is useless; it only becomes useful when it makes us think or act differently.
So when we ask people for their thoughts, interpretations, and applications, not only are we checking for their understanding, but we’re asking them to make use of the information by applying it to their lives.
Example Dialogue
My intent with the following example dialogue, which is inevitably cheesy and unrealistic, is to show how these steps fit together and what they might look like, not to suggest that this works flawlessly every time.
This is a made-up patient with a 5-year history of low back pain whose MRI shows no indication of dangerous pathology but found several herniated discs.
PT: So tell me your understanding of what’s causing or contributing to your back pain (orienting).
Patient: Well, my MRI showed several herniated discs, so it’s probably because of that...
PT: Herniated discs can certainly contribute to pain, and seeing them on the MRI can really freak us out (validating)!
Patient: Yeah, it makes me wonder whether I need surgery…
PT: Yeah, I can understand why you’d feel that way (validating). So what made you come to PT then (orienting)?
Patient: I’m not sure. My physician told me that I should see if physical therapy could help me.
PT: Do you think that it can (orienting)?
Patient: I hope so, but I’m not sure.
PT: That’s understandable (validating). Well, I can tell you that I’ve seen a lot of people with MRIs that look a lot like yours who have been able to reach their goals (providing). Are you willing to give it a shot?
Patient: Yeah, I’m here. But what can PT really do for herniated discs? Can we push them back in?
PT: Good question (validating). There are two things that might be helpful to know (providing). One is that there is a fair portion of people whose herniated discs do go back in; it’s a phenomenon called ‘spontaneous regression’. There are also people whose discs don’t go back in, but their symptoms improve anyway—without surgery. What do you make of that (eliciting)?
A few things to highlight...
First is that the steps are not necessarily linear; they are constantly being cycled through.
Second is that the PT didn’t go directly after the person’s belief about their herniated discs causing their pain. This is for two main reasons:
The first point is that we don’t—nor can we—know how much or how little the person’s disc is contributing to their symptoms. No—it isn’t the sole cause because that’s not how pain works. But it’s absolutely possible that a bucketload of nociceptive input from the periphery is reaching the brain and contributing to the symptoms.
The second point is that in my experience, at least at the beginning of the relationship, it seldom goes well to try and directly refute a person’s beliefs. I find it much more helpful to focus on their concerns than their beliefs. Once the person’s symptoms start to improve, the relationship strengthens, or both, then it might be useful to go deeper into how pain works and how common asymptomatic herniated discs are. But in the beginning, we just need to get on the same page and start working together.
HOWEVER, this does NOT mean that we should reinforce unhelpful beliefs—a very fine line.
In summary,
bypassing beliefs and addressing people’s concerns is often helpful in the beginning. We can always educate more in the future. At the same time, we should take care not to reinforce unhelpful beliefs.
Action Item
Choose one of the phases of effective patient education (orienting, validating, providing, eliciting) to focus on for the next week or two.
Use some of the strategies discussed in the Law I article to help you build the habit.
I put together an infographic of the 5 habit formation strategies that I discussed in Law I to make your life easier:
In summary
1. Help them make sense of their problem.
a. To improve treatment adherence/compliance
b. Because if we really want to help people, we need to teach them to reason & problem-solve
c. Because we can’t do it on our own—we need them to apply it to their lives
2. We cannot (nor should we) attempt to change people’s beliefs.
3. We can (and should) work with people to help them come to an understanding of their problem that is more helpful for them.
4. The 4 steps of effective patient education:
a. Orienting
b. Validating
c. Providing
d. Eliciting
5. Bypass people’s beliefs and instead address their concerns directly (without reinforcing unhelpful beliefs).
Thank you so much for reading. I’d love to hear from you! Please let me know your thoughts in the comments below, and share with friends who you think would enjoy too!
Sincerely,
Andrew