“Reflection can involve several cognitive activities that lead to stronger learning: retrieving knowledge and earlier training from memory, connecting those to new experiences, and visualizing and mentally rehearsing what you might do differently next time.”–Dr. Mike Ebersold, MD, from the book Make it Stick: The Science of Successful Learning
Tell me if this has happened to you. You’re just winding down a treatment session, when another patient (not yours) says to your patient, “why don’t you get any heat? You should really get heat. Ask him to get you some heat.” So I glance over and see that incredulous look that says, ‘yeah, why haven’t you ever offered me heat?’ And then comes the question: “do you not do that?” Great. I’ve spent the last two months building rapport, establishing credibility, and in the span of four seconds a nice crack just got put in the foundation.
Normally, I like it when patients interact. It usually provides for a more fun, engaging atmosphere. But there are risks associated with it. One risk is the exchanging of misinformation. Patients often like to share with each other what they have going on, what their injury and rehab experiences have been like, and what “knowledge” they’ve gained along the way. However, more often than not, their knowledge base consists of the conventional wisdom regarding their issue. As John Kenneth Galbraith said, “conventional wisdom is the view that serves to protect us from the painful job of thinking.” And the more misinformation people here, the more they tend to think of it as the truth.
“The world in our heads is not a precise replica of reality; our expectations about the frequency of events are distorted by the prevalence and emotional intensity of the messages to which we are exposed.”–Daniel Kahneman
I very rarely use modalities (heat, ice, e-stim, ultrasound). On the rare occasion I have acquiesced, it is when specifically requested by a customer due to their perception of success with a previous experience, and only if it will do no harm. Additionally, if in the case where significant peripheral or central pain mechanisms are present, and manual and/or active treatments are not tolerable at the time, I have resorted to the use of modalities with the intent of simply calming down pain and sensitivity. The end goal is to ultimately get them active and moving in a less threatening way.
“So long as what you do is safe and not ripping the patient off, if it works, do it!“–Louis Gifford
So what would you do in this situation? During my initial evaluations, while in a discussion of aggravating or relieving factors, I will often ask patients if they use heat or ice on their own at home. But again, I seldom initiate the offering of it in the clinic. I try to focus primarily on active treatments as opposed to passive ones, and those that increase patient efficacy and empowerment. This particular patient is not one dealing with chronic pain. Yes, pain is a symptom and a limiting factor when it comes to certain activities, but not as much as “weakness” is, according to her. “Yes, heat does feel good, I acknowledged, but is it going to help get you stronger, or increase your endurance? No.”
My biggest concern was this: my clinical “expertise” was undermined so quickly by another patient, one who my patient has had no prior interaction or relationship with. Perhaps it is because they are involved in a shared rehab experience. Perhaps it is they are of similar gender and age. Maybe my patient was simply being nice and playing along, not wanting to upset the other woman. Or perhaps it is because I really didn’t do as good a job as I thought I did in building trust and meeting the patient’s needs. Something to reflect on.
As always, thanks for reading. Comments and discussion welcome.
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
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