"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Sunday, March 27, 2011

Doctor Happy and the Silent Treatment

A new study highlights an old problem in medicine that leads to patient harm.

A new study from VitalSmarts, the American Association of Critical-Care Nurses and the Association of Peri-Operative Registered Nurses (AORN) called The Silent Treatment describes several categories of "undiscussables" in medicine:
  • Dangerous shortcuts
  • Incompetence
  • Disrespect
As I shared here, even physical therapists are subject to events that lead to the silent treatment.

Teams of healthcare workers in the future will need to learn positive ways of influencing each others' behavior but not bullying, yelling or disrespectful behavior.

The silent treatment happens anytime communications between physicians and other workers break down. "Other workers" can include nurses, physicians' assistants, physical therapists or even clerical people. My experience with a particular orthopedic surgeon falls under the "disrespect" catagory.

Acoording to the American Association of Critical-Care Nurses (AACN):
"More than half say disrespect prevented them from getting others to listen to them or respect their professional opinion, and only 16 percent confronted their disrespectful colleague."
My story goes like this:

The orthopedic surgeon called me two weeks after the patient's operation. I had seen the patient once, or maybe twice, at that point, for rehabilitation of his full-thickness rotator cuff repair. The patient was on the standard six week protective protocol, passive range-of-motion only and pendulum exercises at home.

The incision was still swollen and tender. Motion, even passive motion, was quite painful. The patient was still having trouble sleeping at night. Therapy consisted of maybe 20 minutes of passive mobility in six directions, the aforementioned pendulum exercises followed by electrical stimulation and ice.

I got called in the middle of the work day by the physician who we'll call Dr. Happy. When I picked up the phone, Dr. Happy practically yelled,
"Tim! What the hell are you doing letting my patient get stiff?"

I knew better than to argue. "He's still very sore, Dr. Happy" I said.

Dr. Happy continued, "You'd better improve internal rotation! He can't get his arm up his back! He's going to get a frozen shoulder!"

"We won't let that happen, Dr. Happy!"
I said.
That might have been enough - a sharply worded reminder to improve joint motion - except for what came next.
"You like my referrals - don't you?". It wasn't a question.

"Yes sir!" I said, dreading what I knew was to follow.

"You'd better not let him freeze up or I won't send any more referrals to your clinic!" growled Dr. Happy
The question is not whether Dr. Happy was justified in chewing my butt, or whether my patient actually was stiffening up (he wasn't).

The questionable behavior is Dr. Happy's abusive, disrespectful and bullying attitude that, unfortunately, was not seen as abnormal in the culture of American medicine.

Nowadays, hospital safety is changing as a result of checklists, computerized decision support tools and new surgical protocols. But, these new tools won't create a safe culture as long as people disrespect each other to enforce a culture of silence.

Tools don't create safety, people create safety.

The culture of silence is beginning to change.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

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