Ethics in Practice The Perils of Posting A PT gets exercised, with problematic results. By Nancy R. Kirsch, PT, DPT, PhD, FAPTA | March 2019 What's the appropriate response to negative online feedback by a dissatisfied recipient of physical therapist (PT) services? What if the criticism is wildly off-base? What are the dangers of responding? Is response even necessary? Consider the issues raised by the following scenario. Tempest in a Treatment Room Jeff is a PT at Eastside Physical Therapy, a thriving practice in a close-in suburb of a major city. Business is so good, in fact, that the clinic has recently extended its hours to 7:30 pm, although Eastside isn't yet scheduling a full complement of patients in the day's final time slot. Jeff has volunteered to take some of these late appointments, because the early-career clinician is the only single and unattached PT on staff. "You go and enjoy dinner with your families and significant others while I slave away here, burning the 7:30 oil," he jokes to his colleagues. Jeff very much enjoys his work, although dealing day-in and day-out with a busy and demanding patient and client base has its challenges. While most of Jeff's patients and clients are great, some can be impatient and a bit abrasive. Jeff has earned high marks from management for his success in "soothing the savage beast," as his physical therapist assistant colleague Marcy puts it. His innate friendliness and self-effacing manner have disarmed many a testy ego. Marcy calls him "the patient whisperer." In Leslie, however, Jeff may have met his match. The new patient—self-referring for recurring mild ankle sprains—arrives 15 minutes late for her 5:30 pm appointment. Jeff uses the time to check in on another patient. When he introduces himself to Leslie at about 5:55 pm, pique is written all over her face. As she hands him her intake paperwork—which she's just finished—she follows a perfunctory "Nice to meet you" with the immediate note that "we'd better make this quick," because she has a pressing appointment several minutes' drive away at 7 pm. "We'll certainly do our best," a smiling Jeff says, adding, "I guess traffic was pretty bad getting over here?" While he's simply seeking to acknowledge that forces outside of her control likely caused her delay, Leslie takes offense and shoots back, "What's that supposed to mean? Anyway, I didn't see you around anywhere when I got here. So, I can't say when, exactly, you would've been ready for me, anyway." Jeff doesn't take the bait, instead noting in a friendly tone, "Well, we're both here now, so let's get started." He settles Leslie into a treatment room and asks her to remove her shoes and socks while he quickly looks in on another patient who's just beginning mat work with Marcy. When he returns less than 2 minutes later, Leslie is just getting off the phone. What Jeff hears her say is, "I'll be there as soon as I can—hopefully on time, but nobody here seems to be in much of a hurry. And they're quick to blame the patient for any delays." The PT doesn't respond to Leslie's dig, though it's obvious that he overheard her comments. Jeff begins his history and physical examination, determined to win her over yet with his undivided attention. But she's clearly annoyed and offers only terse responses to his questions. What she does say, however, strikes Jeff as contradictory: She needs him to strengthen her ankles so that she can train for an upcoming half-marathon, but she doesn't have time to exercise, "so that's a nonstarter." "Let's focus on the good news," Jeff advises. "I'm definitely seeing ankle weakness, but with 2 visits a week for the next 3 weeks and an extensive home exercise program—sorry for uttering the 'e word,'" he adds in an playfully apologetic tone—"you should be in good shape for that race next month." The PT is taken aback by Leslie's response. "Are you deaf?" she exclaims. "I came to this clinic, and I specifically booked an appointment with you, because of all the good things I read online about how you work with patients to meet their needs and obtain efficient and effective results. But maybe you people ghostwrite all your own comments, because I'm not seeing any willingness to work with me here! If you can't use your advertised expertise in physical therapy to fix my problem in the manner that I need you to fix it, I'll have to look elsewhere for help." Struggling to retain his composure, Jeff rejoins, in what he hopes is a calm, reasoned voice, "Patient care is a collaborative process. By working together, we can meet your goal of competing in the race," he says "It's going to take a bit of work on your part, sure, but I'll be supporting you every step of the way. Okay, then? I'm just going to print out your home program and will be right back." When Jeff returns to the room, Leslie has her socks and shoes back on and is heading to the treatment room door. He extends the printed exercise program to her, but she says, "Keep it. I am out of here! I've had enough of your condescending attitude and your 'my way or the highway' approach. If you think I'm ever coming back here, you're crazy!" After she storms out, Jeff sits down, stunned, and tries to understand what has just happened. How did things get out of hand so quickly? What might he have done differently? What if he hadn't made that initial well-meaning comment about traffic? Could he have better explained why exercise is vital to the recovery process? Should he have quickly shared tips on fitting exercise into a busy schedule? He decides that he'll reach out to Leslie tomorrow—apologizing for any miscommunication and offering a "restart" if she'll give Eastside another chance. Perhaps the pressure of her pending appointment, combined with whatever else has been going on in Leslie's life today, got the best of her, Jeff reasons. Maybe this will end up being a case of "what a difference a day makes." Before Jeff even leaves for work the next morning, however, he gets a text from Victor, who monitors various consumer-comment websites for Eastside, informing him that "some lady's got a monster-size bee in her bonnet about Eastside—and about you in particular." When Jeff reads Leslie's comments—a diatribe filled with distortions, vitriol, and outright lies—he no longer can contain himself. "May the record show," Jeff posts in response, "that I'm the 'smug' physical therapist who 'couldn't care less' about his patients. In fact, I care deeply, as scores of them have acknowledged, in the many glowing reviews you'll read on this site and others. So, why the utter disconnect here? "Well," he continues, "it might have something to do with the fact that the patient in question expressed a total unwillingness to do the exercise required to strengthen her ankles for that race she mentions. It also might have to do with her having been late for her appointment, then suggesting that the tight timeframe was my fault. Anyone can get up on the wrong side of the bed every once in a while, but this lady treated me like she's never seen the right side of the bed." Jeff doesn't have much time to feel satisfaction about his response, however. Less than 10 minutes later, his boss, Linda, phones, having also been apprised of the situation by Victor and having visited the consumer site. She is furious at him, and not at Eastside's irate ex-patient. "What were you thinking?" Linda nearly shouts. "Or were you thinking at all? Patients get upset! Sometimes there's nothing to be done about it. Or, we might choose to reply, as a practice, in some measured and responsible way. But you can't just go shooting off your mouth, sharing a patient's protected health information over the internet, and matching insults with that individual—even if she's got a screw loose, as I imagine this lady does, from what you wrote and what a few people in the clinic overheard and shared with me. "Look," she continues, "I know how great you usually are with patients. I'm sure you were respectful to this woman yesterday, and reading her hysterical comments first thing in the morning felt like the last straw to you. But this is a case of seriously poor judgment. I want to see you in my office first thing this morning, because you and I have a lot more to talk about." Jeff feels a bit shell-shocked after he hangs up. Had he no right to set the record straight? Shouldn't such blatant falsehoods be fully addressed, so consumers get the full and accurate story? Anyway, even if he did act a bit rashly, isn't Linda overreacting? For Reflection "Word of mouth" isn't what it used to be. Before the internet, patients might discuss their experiences with physical therapy—positive or negative—within their circle of family and friends. Now, however, such accounts exist on websites that may be visited by a wide range of current and potential customers. Our human tendency is to respond to criticism we deem incomplete or unfair, but doing so as a health care provider may be ill-advised or even illegal. Have there been moments in your career when you've imprudently crossed a line, or at least been sorely tempted to? Do you look at the situation differently now? For Followup If you are reading the print version of this column, go online to www.apta.org/PTinMotion/2019/3/Ethics inPractice/ for a selection of reader responses to the scenario, as well as my views on how the situation might be handled. If you are reading this column online, simply scroll down to the heading "Author Afternote." Be aware, however, that it generally takes a few weeks after initial publication for feedback to achieve sufficient volume to generate this online-only feature. Nancy R. Kirsch, PT, DPT, PhD, a former member of APTA's Ethics and Judicial Committee, is the program director and a professor of physical therapy at Rutgers University in Newark. She also practices in northern New Jersey. ResourcesAt www.apta.org/EthicsProfessionalism/Core ethics documents (including the Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant)Ethical decision-making tools (past Ethics in Practice columns, categorized by ethical principle or standard; the Realm-Individual Process-Situation [RIPS] Model of Ethical Decision-Making; and opinions of APTA's Ethics and Judicial Committee)At www.apta.org/PTinMotion/2006/2/EthicsinAction"Ethical Decision Making: Terminology and Context"Considerations and Ethical Decision-MakingThe prudent course of action—or should we say inaction?—in this case is clearly outlined in the profession's ethical principles involving patients' and clients' best interests, protection of health information, legal dictates, and educational responsibility.Realm. While the realm is individual—between Jeff and Leslie—there are institutional implications for Eastside, as well.Individual process. Jeff's moral motivation should have been to prioritize patient-centric ethical values over his desire to share his side of the story.Ethical situation. The PT has succumbed to an ethical temptation by choosing a wrong action over a right one because he perceives personal benefit in his chosen move.Ethical principles. The following principles of the Code of Ethics for the Physical Therapist offer insight into Jeff's actions and his ideal course: Principle 2A. Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients/clients over the interests of the physical therapist. Principle 2E. Physical therapists shall protect confidential patient/client information and may disclose confidential information to appropriate authorities only when allowed or as required by law. Principle 5A. Physical therapists shall comply with applicable local, state, and federal laws and regulations. Principle 8D. Physical therapists shall educate members of the public about the benefits of physical therapy and the unique role of the physical therapist.Author AfternoteReaders universally remarked that they could feel Jeff's pain. As one PT put it, "If you haven't yet come across a patient like Leslie, believe me, you will."Respondents also agreed that, in the age of social media, dissatisfied patients and clients have a variety of attention-getting and potentially damaging outlets for their discontent. They agreed that Jeff's instinct to apologize the next day and try to defuse Leslie's anger had been appropriate and correct, but they expressed little surprise that Leslie didn't give Jeff the chance to do so before posting her comments online.Readers understood Jeff's decision to respond to Leslie's invective, but opinions differed on the propriety or value of such a response. Several respondents took issue with Jeff's point-by-point rebuttal—which, they wrote, both unduly personalized the matter and, as Linda pointed out, showed poor judgment by sharing protected health information.Many respondents said that Eastside's best course of action would have been to post a measured comment from management—something along the lines of, "The clinic values all of its patients and clients. While we dispute the details of the poster's account of events, we will continue to strive to provide respectful and excellent service." One reader wrote that her employer had taken precisely that approach in a similar situation and had even attracted a new patient in the process. "This patient told us that he was very impressed by the way we'd handled the matter, with restraint and dignity," this respondent noted.Only a few readers felt that Leslie's comment should go unchallenged by Eastside—soon, their thinking was, it would be pushed down the comments list by positive posts from other consumers. However, in today's world, most readers said, defending one's reputation from particularly nasty, misleading, and outright false accusations is important.