Highlighting Humanism in Physiotherapy Practice - Neil Langridge. Physio UK 2019.
Neil Langridge gave a heartfelt and sincere closing presentation with Karen Middleton and Beverley Harden at PhysioUK 2019. The final hours of a fantastic conference left the delegates both reflective and inspired. Neil's spirited contribution looks back on the time he met a patient who was standing at the precipice of the human predicament when investigating a team member's action that concluded with unfortunate consequences. He goes on to discuss the humanity, the nature of being and the leadership opportunities that we are fortunate to develop in our auspicious profession.
"I would like to start with a patient story – some years ago I was asked to investigate why an MRI had not been ordered for a patient with Red Flags – the clinician had not made the needed investigative requests and tragically the patients some months later was diagnosed with widespread metastasis in the spine, and was given months to live. As the Investigating Officer it was my job to investigate and then report back to the patient, clinical team as well as senior executives.
I was asked to meet with her, and due to her condition I was asked to meet her at her house to discuss my findings. I met with her, and effectively listened, offering an apology, yet this seemed so hollow and weak but there was nothing I felt I could do, I felt I could offer no comfort, no acceptable explanation, I could offer no alternative treatment. I felt horrific, and left the house afterwards feeling immense sadness, guilt, empathy and a huge overwhelming sense of a loss of control, I felt I could not do anything of any help whatsoever. I then had to feedback to the clinician, offer support, work with the teams to ensure learning, and explain to our senior leadership teams what I had done in terms of process. I really felt the “emotional” side of the patient interaction on that day.
What dawned on me afterwards (which for many of you will be clear in your practice), but for me it was a stark reminder – in every element of our practice we deal in emotions, relationships, social interactions, around different cultural scenarios, - we build our moral codes around a model of clinical knowledge that is proposed to support patients – and so our clinical decisions as much as I felt in the past were systematic assessments of the clinical evidence in front of me and that these ultimately led to a rational decision are critically influenced by our humanistic emotions .
What I realised through reflection that in the past I had perhaps used “treatment processes” and “rationales for failed treatments” as a protective mechanism due to fear of dealing with these emotional elements of disability and injury, and perhaps the “cloak” that I used to protect myself from these difficult emotions were the “treatments” that I offered for example (applying a treatment is one clear description that does not link the clinician to the patient. – It distances oneself) and I clearly thought of these treatments as a process of delivery, when in reality the treatment itself is more interactive and emotional (less of a process) and the ability to develop a working relationship with the patients I was trying to support needed to be built upon a modelled approach around what the patient required, and this I concluded was far more of a treatment and positive effect on outcome than I was perhaps willing to accept in the past.
The patient in the story required me to be there, although I was feeling powerless and a reduction in worth, I needed to realise the worth at that time was not in the action of doing, but in the action of being, and how that the relationship built however challenging and emotional, was the foundation of the interaction, and that was something I needed to learn from, and certainly not shy away from.
It began to alter my views on a number of work related concepts, clinical reasoning, the evidence-base, the management of complexity, and leadership at a grounded level. As the physiotherapy offer in many areas of practice has rapidly begun to flourish – I was placed into situations where I applied a more humanistic-intuitive approach, which had an acceptance of emotion and interaction when before I looked for answers grounded in what I assumed to be strong scientific evidence devoid of the human/social element and so I began to see how this cannot be ignored when in tough, challenging and new situations; I believe that with the advent of so many opportunities the profession needs to consider how the systematic assessment of patients, services, and multi-professional working must be intertwined with a humanistic-intuitive emotion accepting approach – I believe that applying this approach can move ideas and improve patient care with more success, and at greater pace.
Let’s take a first example; Clinical reasoning – In my field of MSK it CR has a wide-ranging set of principles and models surrounding decision-making, yet so many fail to recognise the emotional, intuitive elements of this as these perhaps are less tangible, and do not deliver a sense of concrete clinical evidence, when perhaps most of our clinical decisions are linked associative memories that are emotional markers and the relevance and priority of those are highlighted to us by the feelings and physical reactions that they produce - we don’t really diagnose and plan through algorithms that we can just all work by
Higher stress for example can improve decision-making, a number of studies have concluded that managed stress can enhance sped of thought and accuracy (for example in emergency care), physiological responses such as nervousness in the stomach; sweating, increased breathing rate can be markers that highlight when the relevance of a decision has greater links to our own emotional markers. By exploring these in reflective practice we can understand ourselves better, and also utilise parts of our decision-making that we may not normally access.
Intuitive elements are perhaps our ability to realise the emotional state of others and tailor our own emotional responses to aid in or communication and relationship building and as a clinician, trying to enhance intuitive reasoning within my own systematic approaches has been highly valuable, I would advocate strongly in all elements of reflective practice the opportunity to explore intuition and feelings as part of a clinical diagnosis – it may be conflicted against what may hold true as what “clinical evidence” is – however its highly relevant in decision-making.
As a profession, the Evidence-based model has rattled along in physiotherapy at great pace – systematic approaches to patient care, numerous examples driven by controlled trials comparing numerous treatment approaches have been published across all domains of practice. The challenge to all of us is applying this across populations and to individuals all with unimaginable complexities and differences in their lives, cultures, beliefs – yet we try to standardise against an individual’s clinical presentation, which does not commonly offer a social understanding of the problem, it tends to offer an anatomical/clinical description. Unsurprisingly we approach this in a narrow model aiming to link to the evidence base which I would argue in a number of areas is not person-centred (emotions/relationships/belief) but modelled on clinical descriptor (OA, Parkinson’s disease, COPD) of course those are vital but with so many new models of care emerging, is this the time for considering a re-frame of much of what we do, say, propose to patients? Let’s take clinical practice;
I see a huge value in LTC management in emphasising how physiotherapy is THE profession to deliver change across a wide range of health sectors – our abilities in supporting self-determination and self-actualisation for patients in their rehabilitation programmes can be easily identified – SDT requires the patient to experience autonomy (being in control), competence (the need to feel effective) and relatedness (the need to feel valued) and perhaps also the cited term integrated motivation where individuals gain a sense of enjoyment and fun from an externally set goal – this is what we do - when I think about my “treatments” I was missing the context – I was assuming the predominant factors were physiological, when the psychological benefits were a poor/not measurable partner, they are in reality integrated and driven by the humanistic relationships of care given and received. As a profession we are in a perfect role to develop these factors and enhance outcomes for our patients – why do some treatments work better on some than others, why do patients suddenly progress/respond -? I can’t tell you – but what I do believe is that the physiotherapist as a behaviourist is a concept I really value and I really believe this is a major factor in changing outcomes. The coaching model and behaviourist approach challenges the concept of treatment improving outcome, it for me enhances the NATURE of the Physiotherapist – that is the HEART of the profession –it is the individual characteristics of a profession that is central to the success of the evidence base – what I mean by this is look to what Physiotherapy offers in terms of empowering individuals, communities, influencing policy and therefore the health of the nation – these are the factors I would want to see impact – this is where we can impact and this is where research blends so well with what we can offer.
Lastly, I really considered the effective of emotion and humanistic values on leadership and influence, and how this will maintain and develop our opportunities. I have found usefulness in considering how a coaching/humanistic model develops oneself and others, builds MDT relationships and allows for the grasping a really bright future going forward. I truly believe that our skills in coaching, developing working relationships and clinical relationships that have to last the test of time are fantastically aligned to leadership principles. As a profession we are clearly aligned to harness these communication skills, building in autonomy for patients, developing clear plans/prognoses and supporting carers and loved ones at the same time, exploring how the MDT can truly give a rounded care programme, and by doing so we can realise how these skills are eminently transferable to leading and empowering those around us and not just our patients.
Clear leadership is embedded in our practice, its perhaps just about scaling it up and realising that our profession develops natural leadership qualities and the blend of skills around the enhancement of a patients abilities to succeed, the skills around shared-decision making and principles of goal setting, enhanced by a team ethos and underpinned by the science and humanistic approach to evidence and care with a clear moral transparency are for me a heady mix that naturally defines and aligns to health leadership for the future.
Clinicians are leaders – these are not separate entities! – the development of new non-medicalised models, the population health challenges, the advent of technology, and the economic status we all find ourselves in continually is met head on by our profession and that of course is everyone in this room – I truly believe that with the acknowledgement and realisation that our profession has the natural relationship with change models and health leadership at every grade - we can really realise our potential and make the difference that we all originally went into the profession for.
My final message links back to the patient story; recognition of the humanistic effect our profession could have on our population is the first realisation, the second is how the skills of humanistic coaching towards self-actualisation are skills of leadership and if pushed to their potential could really see the opportunity our profession has to offer be a realisation.
The NHS England “Long term Plan” is where all our skills could be utilised clearly and effectively; The emphasis on prevention, workforce transformation and re-design and utilising technology are clear opportunities to contribute to the agenda, influence the health of the nation and be part of effective change.
As a profession we can be leaders in driving the national agenda and this may at times seem a distant dream, but we are making that happen, yet without the ground level fantastic delivery of practice, with the amazing humanistic skills each and every clinician brings –new policy and implementation is futile – we make things happen, bits of paper, documents, policies - they just give the permission.