I’ve felt for a while now that my goal as a physical therapist is to be able to sit down with someone as if to say, “How can I help you? I have a set of specific knowledge, skills, and expertise and I’d like to help you as best as I can. And if I can’t help you, I’m going to help you to find someone who can.”
It sounds so simple. So what makes it so difficult to execute this in the clinic?
In this article, we’re going to deep dive into one aspect of this predicament: the roles we play.
How to make sense of roles
Some problems with the roles that we play
How to skillfully navigate these roles.
For all you readers out there, the concepts explored in this episode are heavily influenced by a book that I can’t recommend highly enough called How Can I Help? It’s a very non-technical read with stories woven throughout. It’s very deep and very good.
OK let’s dive in.
The Roles We Play
Have you ever had the experience where you move away from home—say for college, graduate school, or otherwise—and you change?
You’ve been away from home; in new contexts, new environments, met new people, and you’ve grown. You’re not the same as you were when you left.
And then you come home for a holiday, and you get around your family or friends, and you find yourself acting in the exact way you did when you left— as if nothing had changed.
You end up having the same types of conversations with family or friends that you did in the past. You fall into familiar little arguments with your family members. You fall back into the cadence of your relationships, which have been well worn, like tire marks on an old dirt road.
What happened to the changes? What happened to the new you?
We all play roles in our lives and often define ourselves by our roles.
I am a physical therapist, I am a man. I am a husband. I am a dog dad. I am a skateboarder. I am a reader. I am a meditator. I am a son, a brother, a cousin.
And we act out these roles, shapeshifting to fit the role we’re called to play at each moment based on the context of the situation.
But who are you, really? Who are you behind all the roles? Not an easy question (but don't worry, we won't go that deep right now. That question is for you and Alan Watts to sort out).
The Problem With Roles
The problem arises, though, when we identify with the roles that we’re playing.
If I identify with my physical therapist role, what I’m saying at that moment is that’s who I am—I’m a physical therapist:
I am the physical therapist and you are the patient. I have the knowledge and I need to educate you. Did you do your exercises? You should really do your exercises. If you don’t do your exercises you might as well not come. You’re not being a very compliant patient right now. Do you even want to get better?
And while I’m busy playing the PT role, what happens with the person I’m working with? Well, they often fall into the patient role.
What does the patient role look like? Well, that of course depends on the person and their past experiences with healthcare providers, as well as the way in which I’m playing the PT role. But we can be sure that playing the patient role is different from being a person attending physical therapy.
And when people don’t fall into the patient role, we often get frustrated:
My patient isn’t listening to me. I keep educating my patient but they aren’t doing what I say. They just do whatever they want.
The thrust of the problem is twofold.
1. If I’m identified with the role of physical therapist, I’m leaving out a significant portion of who I am. I’m holding fast to a particular aspect of my identity and leaving out much more.
And I have so much more to offer my patients when I acknowledge the other parts of myself and bring them into the room when necessary.
It’s so much easier for me to understand and relate to my patients when I bring the other parts of myself to work with me
I’m better able to think outside the box and work with the person to navigate through their problems when I let the other parts of myself help
I have more fun and feel less burned out when I’m not suppressing parts of myself
2. The second problem is this: How does someone stop coming to PT (i.e. what happens when they are discharged)? They stop being a patient.
But if they’re identified with the patient role, and feel very comfortable and safe in the patient role, and I’m constantly reinforcing the patient role by my own identification with the PT role, why would they stop coming? Why would they feel empowered enough to venture out on their own? They’re a patient— patients get care, that’s what patients do!
At the end of the day what we find is that often this professional-patient role-playing has a lot to do with power dynamics, where the one playing the professional role holds the power while the one playing the patient role does not.
If what we truly want is to empower our patients, we need to find a way to navigate these roles skillfully.
Another massive downside to these roles that we play is that they keep us separate.
They keep us from connecting on a deeper level. And I think that’s partially why we play the role; because it’s more comfortable to keep some distance between us and our patients.
-But we have to keep distance between ourselves and our patients—that’s part of being a professional.
-Is that true though?
In an article entitled Toward a Normative Definition of Medial Professionalism, Dr. Herbert Swick outlines 9 behaviors that constitute medical professionalism, none of which have anything to do with boundaries, separation, or distance.
In fact, one of the 9 core behaviors is that "Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness."
He goes on to say,
“Some might argue that humanistic values are not requisite to professional behavior, that a physician can exemplify professionalism without humanism. Yet values such as compassion, altruism, integrity, and trustworthiness are so central to the nature of the physician’s work, no matter what form that work takes, that no physician can truly be effective without holding deeply such values. The practice of medicine is a human endeavor. To address the needs of their patients, physicians must ensure that humanistic values remain central to their professional work.”
If we wish to meet our patients on a human-to-human level, we’ve got to learn to see through the roles.
Another way of looking at this is to simply as yourself what it is you want in a healthcare provider.
Do you want a thick wall of roles and professionalism between you and them?
I don’t know about you, but I want a human being who has a specialized set of knowledge, skills, and expertise; not a physician, nurse, or physical therapist.
When I was in residency, it was found out that I had degenerative retinal detachments in both eyes, right worse than left. I had no symptoms (that I was aware of) so we had no idea how long they’d been there, making it nearly impossible to determine what might happen in the future. I had to make a decision whether to get very invasive eye surgery, a minimally invasive laser procedure, or do nothing; all of which had clear pros and cons. And I had to make this decision for each eye.
Luckily for me, the surgeon was an amazing human. He was honest about the difficulty of the decision, patiently talked with me, answered my questions, had open discussions with his fellow in front of me and even told me what he would do if he were me.
All of this culminated in me not just making a decision but making a decision that I was confident in. I trusted myself and I trusted him. I decided to have the invasive surgery on the right and watch and wait on the left, and things have been good so far (we’re about four years out)!
And yes, he is also a great surgeon— he was the chief of the unit at Johns Hopkins. But the very important point here is that you shouldn’t have to choose between a human and a medical professional and neither should your patients.
You don’t have to choose between being a great PT and loosening your grip on playing one. In fact, what I’ve found is that the less identified I am with the PT role, the better I am at my job.
Let me be very clear here:
I’m in no way saying that you should show up to work tomorrow and reject the notion that you are a physical therapist— you are still a physical therapist.
But you’re also a human being, just as your patients are also human beings.
The trick is to play the roles, but do it consciously:
You play the role while knowing that you’re not the role
You use your knowledge, skills, and expertise while knowing that you’re more than your knowledge, skills, and expertise
Ultimately— you play the role when the situation calls for it, and cut through the roles to meet behind them whenever you can
I was talking to a friend recently who runs a personal training business that is very medically-oriented in the sense that they work mostly with a medically-complex population.
He employs physical therapists and occupational therapists who work as trainers for him, as well as trainers who are not PTs and OTs. And he was telling me about how he’s had some difficulty with the PTs and OTs with things like their compassion and their engagement with the clients.
He’s noticed that they, compared to the personal trainers with no formal medical training, tended to be less engaged in the process with the client, but rather tended to instruct them and cue them and more or less sit back.
He’s gotten feedback from clients that they didn’t like that as much as they liked working with the trainers who were right there with them, engaged in the process with them. He’s also noticed on some instances that the outcomes of the clients working with the trainers were better than those working with the PTs and OTs.
As I was listening to him tell me about this, I kept thinking, “This was me. This is me.”
So much of this stuff runs all the way back to our training, and even before our training when we were choosing our career path and developing ideas about what a physical therapist is.
And then we go and spend a ridiculous amount of money on school
And we put a tremendous amount of time and effort into our training
And when we’re in school, we’re working and working, waiting for the day we can say, “I am a Physical Therapist.”
And our family and friends are supportive of us and are very proud of us and excited for us
And our training is all about how to be a PT: how to examine people, how to treat them, how to educate them, how to screen for dangerous pathologies
And all of this training is wrapped in the package of this is what it means to be a PT, this is what being a PT is all about
So it only makes sense that we would identify with this role, we’ve invested so much into it. For many of us, it’s the biggest achievement of our life.
And It took me a lot of time and reflection to realize that all of that—all of that which makes up and encompasses the PT role—is extremely useful and absolutely necessary at certain times, and it’s utterly useless at other times.
It’s extremely useful when we’re working with someone who is deep in the patient role for one reason or another, and wants us to play the PT role
It’s not so useful when the person isn’t in the patient role, and just wants some simple advice or explanations or exercises
It’s useful when the person has potentially dangerous signs and symptoms and we need to collect data and make a decision about how to help them avoid harm
It’s not so useful when we’re working with a person with no potentially dangerous signs or symptoms, but is suffering immensely and who we might not be able to help
It’s such an important skill, to be able to know when to put on that hat and when to take it off and meet human to human.
There are no simple answers, there are no heuristics, it’s about deeply listening to what help the patient is looking for and being quiet enough within yourself to hear it.
Ultimately I believe that we’re here to help the person in front of us, in whatever way they want to be helped, so long as they are safe and we’re practicing in a way that’s legal, ethical, and socially responsible.
So we skillfully move in and out of the PT role as the situation calls for it, and we cut through it whenever we can to meet on the human-to-human level.
I recently published a letter on my blog entitled Dear Patient: A Letter of Intent. I want to close with the last few lines:
So may I meet you today as a human being, free from the roles that keep us separate,
and may I sit down across from you—my fellow human being—with an open heart, an open mind, and a singular question:
How can I help?
Thanks so much for reading! If you want to learn more about ways that you can improve your practice, sign up for a free consultation for my mentorship services. We can discuss your goals & decide together what would work best for you.
Swick, H. M. (2000). Toward a normative definition of medical professionalism. Academic medicine, 75(6), 612-616.