*this is another post that is geared more towards clinicians and students; however, if you’re a patient or client of a physical therapist, I would love to hear your thoughts!
My last post centered around the importance of communicating with our patients – especially getting to know them and giving them a space to voice their fears, concerns, hopes, and questions. I spoke there of how I struggled with this during my first internship, but that’s not the only aspect of communication that I had a hard time with. Something that I really grappled with – and something I still haven’t quite got the hang of – is how to navigate conversation with a patient DURING EXERCISE.
We were all (hopefully) taught in school how to take a good subjective examination. We learned how to sit and listen and “follow the thread” of the patient’s story. At Duke, we even got to practice this – on patient actors, and during role-play with each other. But we never practiced this on a patient who was exercising – it was always a sit-down conversation.
Those sit-down conversations are great, and often you will need to take a few minutes of one on one at the beginning of a session to check in with your patient – how are they doing? how did they feel after their last session? This is really important, as it clues you in about how hard (or not) to push them with exercise and how much time you want to spend on manual therapy, as well as what interventions you might choose. But eventually, you need to get that person up and moving….
…..And there’s a lot to keep track of once they’re on the gym floor with dumbbells in hand! They are concentrating on the movement, you’re scrambling to WATCH their movement for flaws – but you also don’t want to count reps or have awkward dead silences. MOST patients should be spending the majority of their sessions doing therapeutic exercise, and that’s valuable time that you could also be spending creating a bond or an alliance with them through conversation. Again, easy during a sit down 1:1, but when you throw in the exercise element, it can get a little awkward. Here are some things I learned on my first clinical that can help you get the most out of your time with patients – both in terms of exercise and in terms of conversation.
First- The Amount of Chatting you do depends on the patient!
Have a patient that needs a distraction from their fatigue/pain/lethargy? Or one that doesn’t enjoy exercise? Or an athlete that wants to do high level stuff but they’re post-op and relegated to glute sets? Distract them with conversation! For a lot of patients, this makes exercise – and coming to see you for physical therapy – FUN. With these people, chat away. If you, like me, are an introvert that hates small talk – don’t be afraid to open bigger topics during exercise. Again, if your goal is to keep patients entertained, distract them from discomfort during exercise, and build a relationship with them, they’ll likely appreciate going more in-depth with you. If nothing else, please talk to your patient during glute sets. It’s an awkward exercise to begin with, and you being silent or counting reps does NOT help LOL.
Other patients chat so much that they let their form slide, or – quite frankly -they’re not working as hard as they need to be to get tissue adaptation. Instead of stonewalling these people (seriously not cool..), direct their attention towards their body. Ask them questions like “where do you feel the muscles working?” “is this easy, medium, or hard?”. If they say they don’t feel it, or that it’s easy – increase the load. They’ll probably stop chatting and focus in on what they’re doing.
Some patients, especially athletes, like to be hyperfocused on what they’re doing. Alternatively, perhaps you’re challenging them so much that they’re sweating and out of breath (don’t be afraid to do this in clinic! Tissue adaptation only occurs with overload, after all). I’ve found that when I try to chat with these people, I get grunts and one-word answers. And indeed, this is how I am as a patient – I’ve had several excellent physical therapists who gave me workouts that left me sweating bullets. They’d try to ask me where my fiance and I were going for date night and I’d be like “I can’t even breathe enough to answer you right now”. With these people, chatting at all is likely not a great option – but that doesn’t mean that you should fall silent and just count reps!
So….small talk and conversation isn’t always the best thing for every patient during exercise. But you should always maintain connection with them, either verbally or with touch, while they’re working out. Here are some easy ways to do that:
Why the F are they doing this exercise anyway? What muscles is it working? Why does this patient need to work those muscles? How does this goofy theraband side-stepping thing relate to the marathon they registered for? How is this going to help with their knee pain? If your patient doesn’t want to chat – or YOU don’t want them to chat – a little education goes a long way. It fills the silence, shows them you’re knowledgeable and trustworthy, and they might even be more likely to actually follow through with their exercises at home once they know the WHY.
Is your patient REALLY doing that exercise perfectly? Even if they are, talk to them about their form. Give them cues – “sit back into your hips”, “draw your shoulder down and back”, “put your weight through your heels” etc etc. Verbal cues not doing it for you? Put your hands on them. Pull their hips back into a squat. Guide their scapula as they elevate their shoulder. Tell them what you are doing with your hands as you do it, and tell them why. And don’t just tell them what they’re doing wrong – build their confidence by pointing out what they’re doing right.
Is your patient working really hard and clearly struggling? Encourage them! Coach them! If you’re at a loss for something to say – how about “you’re doing great!”, “you got this, 30 more seconds!”, “YEAH GIRL”, etc etc. Follow it up with a high-five after they finish the set and you’ve just gained their confidence.
4 CHECK IN
Are they making that face because they’re unsure if they’re doing the exercise right, or because they’re in pain? Check in. How does this exercise feel? How difficult is it? What’s their pain on a scale from 1-10? Some patients will be vocal about this – others won’t tell you if you’re hurting them. ASK. FREQUENTLY.
Overall, know that I’m writing this post because I struggled with these things. I got home from my first clinical and wished I’d done more of the above. But, now that I’ve had time to reflect, I plan to be doing this a lot more throughout the rest of my career! Clinicians, especially introvert clinicians – I hope this helps you fine-tune your interactions. Patients – I hope this helps you and gives you the confidence to connect with your provider.
As my clinical instructor said, “I’ve never had a patient who told me they wanted me to talk LESS”.