"Does that make sense?"
You might think I'm asking you about Obama's new health care plan.
I'm really showing you how I speak to my physical therapy patients every day as I explain their diagnosis and ask for their 'buy-in' for their plan of care.
What I'm actually doing is asking many of my patients to make commitments to lifestyle changes that take their money, attention and time.
Patients with arthritis, hip replacement surgeries, sports injuries and car accident victims all depend on an accurate physical therapists' diagnosis.
Head nods are nice but I need commitment to get patients to adhere to their home exercises.
I'm asking my patients to commit to action-plans that I have made based on my decisions in my physical therapy diagnosis.
What's a Physical Therapy Diagnosis?
Doesn't the doctor do that?
The doctor makes the diagnosis, orders therapy and the therapist follows the orders, right?
Maybe.
What if the diagnosis is "Low Back Pain" (a symptom, not a diagosis) and the orders are "Evaluate and treat"?
Then the physical therapist needs to make a decision.
The physical therapist needs to make a diagnosis.
Different than the Doctor?
The physical therapist may arrive at her decision differently than the doctor.
Ian Edwards, an Australian physical therapist, studied clinical reasoning strategies in physical therapists.
Clinical reasoning strategies are...
"...a way of thinking and taking action within clinical practice."Edwards was able to divide reasoning strategies into two groups:
- Diagnosis
- Management
Diagnosis was further divided into two groups:
- Diagnostic reasoning - linking physical impairments to disability (see the ICF model)
- Narrative reasoning - listening to patient 'stories', beliefs and cultures.
Management was divided into six groups:
- Reasoning about procedure - selecting interventions.
- Interactive reasoning - establishing patient-therapist rapport.
- Collaborative reasoning - setting patient goals and progression of activities based on consensus.
- Reasoning about teaching - assessing the patient's receptivity to and understanding of the therapist's findings.
- Predictive reasoning - 'envisioning future scenarios with patients', eg: getting better.
- Ethical reasoning - ethical and practical barriers to achieving all of the patient's goals.
What's the point?
Physical therapist decision-making can also be divided based on its intended purpose:
- Treatment
- Documentation
Physical therapists, I believe, treat their patients using the following of Edward's reasoning strategies:
- Narrative reasoning
- Interactive reasoning
- Collaborative reasoning
- Reasoning about teaching
Physical therapists document their findings and write their notes and charts using the following of Edward's reasoning strategies:
- Diagnostic reasoning
- Reasoning about procedure
- Predictive reasoning
- Ethical reasoning
The physical therapist's diagnosis is important for the patient's final outcome. Make the wrong diagnosis and the patient doesn't get better.
The physical therapist's notes and charts are important for legal and audit protection, accurate reimbursement, peer communication and patient progress.
Make the wrong decision while writing in the chart and the therapist doesn't get paid, or worse.
Do you understand?
Does that make sense?
