All-Size Health Care Should Fit One
By Stephania Bell, PT
It was impossible to read Eric Topol's recent Washington Post article without cringing. In it, he describes enduring "three months of physical torture" in a physical therapy setting after undergoing a total knee replacement.
Eventually Topol discovered he was among the "2 to 3 percent of patients" who develop arthrofibrosis following knee replacement, a condition he—a physician—had never heard of prior to his personal experience.
The real problem, Topol concluded, was that he was suffering from "one-size-fits-all medicine." Topol makes reference to standard protocols and preprinted exercise sheets that did not account for his worsening condition when describing his initial course of physical therapy, implying an impersonal encounter that overlooked the patient in patient care.
Stories like this are disheartening, whether they appear in a major news publication or are shared in a casual conversation. But as tempting as it might be to pick apart the various missteps Topol ascribes to his initial physical therapist (PT) team, the more important takeaways come from how the story takes a 180-degree turn.
Topol reluctantly embarked on a second course of physical therapist treatment, transferring to a practitioner recommended to him by a friend. He then experienced, as he described it, a "dramatic turnaround" within days. It quickly becomes apparent why this second round of physical therapy was so much more positive: the PT addressed Topol as an individual and built a plan of care accordingly.
I couldn't help but be drawn to the language Topol used to describe this new physical therapy experience, and I have excerpted some of it here along with a few thoughts of my own.
For instance, Topol writes, "In taking a detailed history, [the PT] zoomed in on my decades of osteochondritis dissecans and that I had a frozen shoulder five years ago, which meant that I have a propensity to scarring in joints."
(Me: This level of history taking should be standard for PTs. Underlying health conditions can hint at challenges that may lie ahead. Explaining to the patient how those conditions can potentially impact the course of care can go a long way toward proactively intervening.)
Topol adds that the PT "carefully examined" his knee, then made recommendations for alternate exercises, something he describes as an "individualized" new plan, "epitomized by her handwritten page of instructions."
(Me: PTs' hands are among their best tools. Careful yet deliberate physical examination is integral to establishing trust with a patient, as happened in this case. The prescribed exercises may not have been unique, but the PT's personal touch made an impact here, conveying a plan of care specific to the patient. While there is nothing wrong with using technology to be more efficient, such as computer-generated exercise sheets, personalization of those exercise sheets with patient-specific notes can reinforce that a program is uniquely designed for the patient.)
Topol also notes that his PT would text him every couple of days to check in on "their" knee. He writes, "We built on the initial success with additional gentle exercises."
(Me: Interesting that he says "WE built on the initial success …" His view of the physical therapy experience had become one of a team working successfully together toward a positive outcome. The PT demonstrated genuine concern for this patient by communicating outside of the clinic visit to ensure he was progressing. The patient recognized the therapist's concern for his unique situation.)
The other noteworthy element is what isn't stated. Other than referring generally to exercises, Topol makes no mention of any specific therapeutic intervention. The biggest impact to his experience was not the PT treatment; it was the PT's treatment of him as an individual.
In the end, it wasn't just Topol's first PT who failed him. He resorted to numerous treatments "for which there were no clinical trials to show benefit," yet his symptoms continued to worsen. He received limited guidance from his orthopedic surgeon other than the prospect of additional surgery. After discovering arthrofibrosis, Topol says he was getting desperate: "My surgeon had little to offer except to say that by a year the inflammation should burn out and he could go in through a scope and take out the scar tissue."
The entire health care system should be better than this.
In a better system, all members of the team maintain open dialogue about a patient's care. Is an orthopedic surgery patient's experience not enhanced when the surgeon and the PT communicate with one another? As someone who has had the good fortune of working side by side with orthopedic surgeons, primary care physicians, and other health care providers in both a university sports medicine setting and a multidisciplinary clinical setting, I cannot imagine it any other way. Even if not sharing the same physical space, we as PTs serve our patients better when we work in collaboration with other providers instead of in isolation.
We are not the only providers who subscribe to this concept. Orthopedic surgeons will often tell me they value the perspective the PT has when seeing the patient repeatedly over time instead of in the operating room or brief clinic visits as they typically do. One surgeon offered this analogy: Surgeons get the snapshot of how a patient is doing at 1 specific moment in time; PTs get the whole video.
Robin West, MD, chair of Inova Sports Medicine and head team physician for both the Washington Nationals and Washington Redskins, had this to say in response to Topol's story:
"Dr Topol tells a great story of how important ‘precision medicine' is in all aspects of health care. As an orthopaedic surgeon and professional team physician, I always focus on personalized care and emphasize the importance of working with like-minded physical therapists. Treating patients is not ‘cookie cutter' medicine, and the care from all health care professionals should be focused on individualized care incorporating a comprehensive history, physical exam, and rehabilitation plan. Frequent communication amongst the ‘medical team' is key and will offer patients a chance for the best recovery. The medical team is made up of everyone involved in the patient's care: physicians, physical therapists, athletic trainers, nutritionists, coaches, nurses, and others."
West's perspective is doubly meaningful since she recently has been on the receiving end of physical therapist treatment after sustaining several severe injuries in a bike accident.
"I got to experience the importance of individualized care firsthand a few months ago," West said. "I required two surgeries and extensive physical therapy. I not only had phenomenal surgeons, but I was also blessed to work with exceptional physical therapists. The surgeons and physical therapists provided me with the best individualized care, emphasizing my specific injuries. They constructed a rehabilitation plan based on my injuries, surgeries, and personal goals."
In covering athletes' injuries and recovery processes for my current role at ESPN, these types of stories of one-size-fits-all medicine are relatively rare. While it isn't to say that athletes don't have their own unique challenges, many of them are of a high-enough profile that their care is being closely monitored. Rehabilitation efforts typically are uniquely constructed to fit the athletes as well as their sport and the position they play within that sport. Multiple providers communicate with one another regarding the status of the athlete, and there is no shortage of attention to their progress.
That approach should apply to the care of all patients at all levels. As West points out, "All patients deserve personalized health care and should seek out the medical team that will offer it to them."
When I originally elected to pursue a career in physical therapy, it was a direct result of time spent as a student working in the training room at Princeton University, observing the relationships that formed between patients and their PTs throughout the course of their rehab experience. I chose physical therapy because I believed I would get the opportunity to collaborate with my patients to develop a personalized plan of care—a roadmap of sorts—toward achieving their goals. The execution of the plan would represent the journey with the arrival at the final destination representing mutual success. I was fortunate enough to practice in clinical and teaching environments with peers who shared this view of tailor-made health care, in collaboration with one another and, most important, with our patients.
We ask patients to trust us with their care when they make a choice to seek out PTs. The least we can do is give each one of them the individualized care worthy of that trust.
Explore other posts from the "Narrow the Gap" series.
Stephania Bell, PT, is a board-certified orthopedic clinical specialist and a certified strength and conditioning specialist. She works full time as a senior writer and injury analyst for ESPN and cohosts ESPN Radio's weekday Fantasy Focus Football podcast. Bell also regularly appears on SportsCenter, Fantasy Football Now, and Fantasy Football Kickoff, and she contributes to NFL Insiders, NFL Live, Outside the Lines, and Baseball Tonight.