Complex Presentations: Lessons Learned

With more responsibilities lying on physiotherapists and with many of us working in primary care, having a handful of complex patients every day is not uncommon. On average I see twelve patients a day, three or four are ‘complex’.

By complex I mean different things; a person living with multiple co-morbidities which are often managed with polypharmacy. Often time this means the patient suffers from chronic pain and stubborn neurological symptoms. The umbrella expands to include challenging behaviour, learning disabilities and cognitive disorders.

My experience of working in two countries, Egypt and England, with vast cultural and healthcare differences, has helped me better understand how privileged we are and how important our role is in improving quality of life. I find myself frustrated when I cannot help complex patients as much as I want to; it makes me question if physiotherapy is for me. I think we can all relate to this so as we approach the end of 2019 I’ve taken some time to reflect on things I’ve learnt about managing complexity and I would like to share my musings with you.

Simplicity is Key

No matter how complex your patient’s condition is there is always a way to simplify it. Their story is central to this approach. As i listen to them share their story it gives me an opportunity to pick out their most important problem that we can work on it together. I find this very encouraging especially for my clients who feel they’ve reached the end of the tunnel with no light ahead. Working on an achievable goal can make a huge difference.

An example of this is a recent patient I saw who came to see me for some advice on pain management. Their medical record shows a number of complicated spinal surgeries and mobility was severely restricted as a concequence of postoperative complications as well as dizziness and vertigo. Together we picked one problem to focus on; walking between shops in the town for 5 minutes without looking for a bench to rest. Our plan was to do a timed two minute walk at home, twice a day back and forth-not in circles so that she doesn’t get dizzy- and add half a minute each week. This didn’t cure her condition but it definitely had a positive effect on her life and now we can build on this and progress to the next goal with momentum.

Experiences Count

A simple pain symptom or discomfort can get complicated by other issues. We are all aware of the psychosocial influence and how it alter normal physiology.  Many of the complexity I see is often a concequence over-diagnosis, medical neglect, long waiting times and even patients not feeling listened to.

A few years ago I received a referral for a patient with bilateral knee replacements and was still struggling to regain full movement of the right knee. Initially I found the patient to be unfriendly but as they started telling me their story I understood why they wasn’t happy. Their previous experience of physio had been traumatic as they had fallen twice during previous sessions.  Even though their progress was actually satisfactory the fear of falling again was a blockade to further progression.

Language is another aspect of experience which can dramatically influence patient outcomes. I keep hearing patients saying I damaged my nerves, my spine is crumbled and fused and the doctor told me that I might end up in a wheelchair soon- believe me I’ve heard it. I am positive that wasn’t exactly what the doctor said but it can be scary how patients interpret what you tell them.  Always check if your patients understood what you’ve said- you can save a life by doing this!

Make it Personal

My favourite questions to ask patients are; tell me about your hobbies, what do you like to do in your spare time? I love watching my patients as they sit differently and their eyes brighten up to answer this question. It takes a minute or two but gives a message that you’re interested in what they do and what they care about and they will trust you if you care. In the follow up appointments I always make sure to ask about these crucial parts of their lives. Empathy is critical to what we do and in building therapeutic relationships.

My point is not to underrate challenging cases or make it sound easy but to highlight some of the ways that helped me connect with my patients in a better way. I have a morning mantra when I’m cycling to work of repeating my goals and renewing my intentions. I remind myself to embrace the challenges of my job, smile genuinely to everybody and do the best I can to help my patients.