It’s been 10 months since I graduated from Drexel University and stepped into the clinic holding the title of “Doctor Joe” (please just call me Joe). In the time since graduating, I’ve carried a full caseload, gained valuable experience and learned so much. However, this blog is about a common thread that runs through every PT clinic in the world.
It’s about something that I didn’t learn in school. It’s about something that gets brushed under the rug because it’s hard to deal with. It’s about something that I strive to be more confident with in each interaction. It’s about something that might define healthcare more than anything else.
This blog is about uncertainty and how to deal with it.
Buckle up and stick with me for the next few minutes. I’ll be referencing an article [Zero Pain Is Not The Goal] to supplement my thoughts on the issue of uncertainty – one that our healthcare systems fails to adequately address in both education and practice.
I used to think that pain was the number one reason why people sought out care from a physical therapist. While that “statistic “might hold true, it’s superficial, it doesn’t tell the whole story and it does our profession a massive disservice.
Patients don’t seek physical therapy because they are in pain. Patients seek physical therapy because their pain is interfering with who they are.
“Great health care should begin with clarity about its purpose—and the why for health care has always been the reduction of suffering. This suffering includes physical pain and functional impairment, as well as fear, uncertainty, and confusion. Suffering is, of course, inherent to medicine; the word patient comes from the Latin for ‘one who suffers.'” Zero Pain Is Not The Goal
I first began to suspect this when I experienced a bout of shoulder pain during graduate school. In the beginning, the pain that I experienced was a bother, but nothing more. However, as the pain lingered, it began to effect me on a deeper level. I could deal with the pain but what I couldn’t deal with was the fear that lifting weights would make the pain worse and lead to long term damage. The fear and uncertainty associated with the pain was keeping me from lifting weights how I wanted to lift them. This upset me because at the time, I was in a dark place and lifting weights was the only thing that was bringing me fulfillment – it was my identity (that was a problem within itself). The shoulder pain that I was experiencing was limiting my ability to express who I was, and that was the problem, not the pain itself.
“There is, quite simply, no “getting it right” when it comes to pain. It is both under treated and over treated. It is ubiquitous, subjective, and sometimes feigned. Its experience is influenced by culture and varies among individuals, and its diagnosis easily distorted by bias…. But pain is part of life and part of medicine… giving sufficient analgesia to eliminate all pain for all patients is a wrong target—but so is treating pain insufficiently.” Zero Pain Is Not The Goal
What I needed in that time was God, but that’s a story for another time.
I didn’t need a complete elimination of symptoms, rather, I needed someone to see suffering in me and tell me that it was all going to be ok. I needed someone who was going to walk with me through my difficult situation while providing me with encouragement, guidance and practical advice.
“The what of health care is more than difficult: it is complex. Multiple issues matter to patients, and clinicians must do their best to weigh values that are often in conflict…. Patients want good clinicians, they want coordination, they want good communication, and they want compassion.” Zero Pain Is Not The Goal
In time, with the help of a handful of physical therapists, my shoulder pain subsided and I got back to the gym without limitation. When I now look back at my six month season of shoulder pain, I realize that fear, probable depression and anxiousness all prolonged and heightened the suffering that I endured. It’s also no coincidence that the beginning of my relationship with my soon-to-be wife coincided with the reduction of the pain and the disappearance of the worry that I had consumed my life; she was the distraction that I needed.
“In short, patients place greater emphasis on the how (whether they are receiving care that is compassionate, coordinated, and focused on optimizing their outcomes) than the what (whether their pain is completely controlled). Zero pain is not the goal. The reduction of suffering is—and that is something more complex than analgesia alone.” Zero Pain Is Not The Goal
That experience with shoulder pain and suffering ignited a drive within me to recognize and understand suffering in others. I made it a mission to become comfortable with helping people on a deeper level than the ever elusive elimination of pain.
For the past 10 months, I have started every single initial evaluation by asking the patient to tell me something about them not related to why they are seeking physical therapy. I started doing this as a way to learn more about my patients as people. However, with hundreds of interactions behind me, I can tell you with confidence that 99% of patients relate this question back to why they are seeking physical therapy. In other words, people aren’t seeking care because of pain or impairment. People are seeking care because their pain or impairment(s) is stopping them from doing things that make them, them. People seek help because their identity is being affected on some level.
This is where it gets real, ambiguous and difficult all in the same sentence. It’s a challenge to discharge patients who are still in pain. However, that is part of our profession and something that we will all deal with from now until we hang up the goniometers (mine doesn’t get much use anyway). We can’t get everyone to where they want to be, however, we can leave them better equipped and better off than we found them. I have trouble parting ways with patients who haven’t reached their goals and I think we all do. The dialogue can be challenging in these situations, however, I want to leave you with an interaction from a recent patient who taught me a lot about dealing with uncertainty. This man had been suffering from “chronic back pain” for over five years, it limited him from doing the things that he loved to do and it had become a part of his identity. Following eight weeks of treatment, I discharged this patient because he had met all of his goals and verbally expressed that he was “ready to graduate.” However, when I was looking through his discharge paperwork, I noticed that he had marked (on an outcome measure) that we was still experiencing the same (constant) amount of pain as when he first began treatment (6/10). Being that we didn’t change his pain levels at all, I asked him what he gained from his time in physical therapy. Paraphrased, these were his answers (the last one is the best compliment that I could receive as a physical therapist or as a person) and I want to share them with you…
- “My pain doesn’t define me.”
- “Just because it hurts doesn’t mean that I’m doing damage.”
- “The pain might come and go, but I know how to manage it now.”
- “I’m stronger than I thought.”
- “My back still hurts, but I’m good.”
- “I feel like I gained a friend and I know that you’re are there for me whenever I need you and in whatever I’m dealing with. I know that you believe in me and because of that, I believe in me a little more now too. I’m going to control what I can control and I know that I’m going to be ok. Thank you.”
If you ask me, that’s what it’s all about.
It’s about understanding that we might not be able to get every one to their end goal, but being confident that we can leave people better than we found them. It’s about realizing that pain isn’t something that we can abolish forever, but something that we can reframe and manage. It’s about believing in other people and helping them believe in themselves. It’s about connecting with people and getting to know who they are and what they really want. It’s about being the best person you can be and lifting other people up while using education, best available evidence and patient preferences to guide your decision making.
The world of (outpatient) physical therapy (as well as life in general) is filled with uncertainty and that can be a scary thing, especially for patients who are experiencing pain, feeling vulnerable and are suffering. It’s important to realize that even when we don’t have all of the answers, we can still make a positive difference for the people that we treat. We can still choose to have confidence even when we don’t feel confident because deep down, we can choose to believe in our ability to be compassionate human beings who do their best for the people who need them the most. It’s become apparent to me that we don’t need to “figure things out” right away and it’s even become clear that sometimes, we don’t even have to figure things out all the way. I’ve come to realize that a large part of our job (as PTs) isn’t to fix people or find all of the answers, but rather, to walk hand in hand with our patients through the uncertainty that they are experiencing. People need a guide.
In the end, there are more important things than pain. Each interaction, no matter how small or how brief, has the potential to lift someone up or bring someone down. We can help people respond better to their circumstances and guide them, encourage them and love them along the way.
It’s not always easy, but it’s always worth it.
Thank you for taking the time to read.
I appreciate you.
Joe Rinaldi, PT, DPT