Compliance Matters In the Rough A PT-patient relationship built on golf goes off course. By Nancy R. Kirsch, PT, DPT, PhD, FAPTA | March 2020 Physical therapists tend to be "people people" whose hands-on approach to problem-solving is both literal and figurative. PTs spend more time with their patients than do professionals in many other health care fields. They form close care partnerships with those they serve. But while PTs are taught about the importance of observing and maintaining interpersonal boundaries from the time they are students, practical guidance can be lacking. It's hardly surprising, then, that PTs can be caught off-guard when boundaries shift and motives seem unclear. Consider the following scenario. Linked Karen has been practicing for about a year at Oak Ridge Physical Therapy, the clinic at which she'd completed her final clinical assignment as a PT student. She'd jumped at the opportunity when owner Jim offered her the job, because of the practice's strong patient-centered focus. Oak Ridge's motto is "Professionalism with a personal touch." The clinic routinely receives glowing reviews on social media from current and former patients. Karen is vexed, however, by her initial inability to connect with Mike, who sustained a severe muscle strain in the mid-thoracic region in a recent car accident. He's taciturn and expresses skepticism of physical therapy's ability to help him. This despite the fact that his wife, Gwen, also has been receiving care at Oak Ridge for injuries incurred in the accident and, from what Karen has heard from the PT who's been treating her, is a model patient. "My wife and I are very different people," is all Mike will say about Gwen's experience at Oak Ridge. "Apples and oranges." Karen makes a corny joke about the "fruits" of physical therapy, hoping to raise a smile. No such luck. Mike follows her instructions during their initial sessions, but with a persistent scowl and no apparent enthusiasm. She wonders if he's adhering to his home exercise program, even though he says he is. But then Mike says something during a session one day that creates an opening for a personal connection. "Usually at this time a year I'm looking forward to hitting the links as soon as the snow's gone," he remarks. "With my back, how am I going to get my golf game back by then?" "Back up to par, you mean?" Karen asks with a wink. The question evokes the slightest of grins, which widens into a full smile when the PT adds, "I can't wait to get back on the course myself. My game has really improved since I started working with a pro at Westminster," she says, naming a local club. "I'd be climbing the walls right now if anything was keeping me from pulling out my clubs as soon as possible, so I totally get where you're coming from." "You golf?" Mike face is animated for the first time since Karen met him. "Only since I was 8," the PT responds with a laugh. "Got my first set of clubs the next year. Best Christmas ever." The ice has been broken — figuratively; it's still February in Michigan. From that point on, Karen relates every aspect of Mike's plan of care to golf-related goals, and she and he often talk form, strategy, and favorite courses. Mike becomes an enthusiastic participant in his recovery. Karen no longer wonders whether Mike is faithfully performing his home exercises. Mike occasionally makes comments that give the PT pause, however, such as, "Do you know what it's like to have a spouse who doesn't share your interests?" and "I'd really like to see your swing in action. I'll bet you and I would make a great team against these two guys I know whose mouths are way bigger than their talent." The comments aren't really inappropriate, but there's something about the intensity of his gaze when he says them that makes Karen a little uncomfortable. Since Mike is making good progress, the PT suggests they reduce his visits from three times a week to two. She assumes that he'll welcome the affirmation of progress, so she's surprised when he responds, "The status quo is working just fine for me. Let's keep it going, Doc." It's the first time that Mike — who'd once asked, "Isn't what you PTs do kind of pseudo-science?" — has acknowledged Karen's doctoral degree. She doesn't see any downside to maintaining the thrice-weekly schedule for a while longer, and she's pleased by Mike's determination. But Karen starts to question his motivation when one day he presents her with "a small thank-you gift for helping me get over myself and get it through my thick skull that physical therapy really works." She reaches into the gift bag to find a fun pair of animal-print socks similar to the kinds she often wears to work — which barely show below her pants unless she's engaging patients in stretching exercises or otherwise moving in such a way as to expose her ankles. Karen is touched by the gift, but it suggests that Mike's been watching her a bit more closely than she had imagined. She briefly considers declining the socks, but she likes them, they're inexpensive, and the PT reasons that there's nothing particularly intimate about footwear that features smiling hippos. She even makes a point of wearing the socks on Mike's next visit to emphasize her thanks. He simply smiles and says, "I'm glad you like them." Karen chooses to feel reassured by his low-key reaction that he hadn't meant anything inappropriate. Mike starts reporting a slight uptick in pain and suggests that Karen resume soft tissue work she'd discontinued as no longer being necessary. Karen believes that her timing had been right, but she's willing to grant Mike's request and see if the resumption makes a difference. Sure enough, after some additional soft tissue work Mike reports improvement. He attributes it to her "magic hands" and rewards her with a big tub of chocolate-drizzle caramel corn — their previously discussed mutual snack of choice when watching golf on TV. Karen finds nothing particularly suggestive about the gift, but she's starting to think that, ironically, Mike the one-time skeptic is getting a little too comfortable with physical therapy. She begins lessening their weekly visits and announces her plan to discharge Mike by the end of the month. She notes that Gwen already has completed her time at Oak Ridge and says, "Think about it: Once you and she are both done with physical therapy, in that sense, at least, you'll have put the accident behind you." "Yeah, but what about the accident of my having married Gwen in the first place?" is Mike's unexpected response. Karen is trying to figure out how to answer that when he adds, "The home exercise Gwen was doing while she was coming here was just about the only exercise she's had in the past 20 years. You and she are like night and day! You're in great shape, you care what you look like, and you know how to make a man feel good about himself. Gwen likes nothing better than to sit around the house and complain about her life — and about me. And she wonders why I spend as much time as I can on the golf course." Karen is at a loss for words. "I hope it's not that bad," she finally manages. "Trust me, it is," Mike says. "Anyway, I know our time here is winding down, but I'd really like it if we could stay in touch. We could play some golf together — at the very least. I feel a real chemistry with you. I hope that you feel it, too." So, there's no longer any ambiguity. A married man is interested in her. Karen now sees that he has felt emboldened by her actions. While it's clear to her that she must reject Mike's overture, she can't help wishing that she'd handled things differently — ideally avoiding this extremely uncomfortable moment. For Reflection Karen realizes in retrospect that with regard to Oak Ridge's motto, her professionalism in this situation could have stood improvement, and her personal touch was subject to misinterpretation. Have you been in a situation in your career in which signals you sent a patient may have inadvertently helped cause misunderstanding and even discomfort? If so, did this prompt behavior change on your part? For Follow-up If you are reading the print version of this column, go online to www.apta.org/PTinMotion/2020/3/EthicsinPractice/ for a selection of reader responses to the scenario, as well as my views on how the situation might be addressed. 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, FAPTA, 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/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-MakingKaren's interactions and relationship with Mike reflect questionable judgment and lack of familiarity with principles of the Code of Ethics for the Physical Therapist.Realm. The realm here is individual — between Karen and her patient, Mike.Individual process. Karen's inability to appropriately recognize, interpret, and frame the deepening situation with Mike reflects a lack of moral sensitivity.Ethical situation. This is a problem or issue — a situation in which important moral values are being challenged. By accepting Mike's gifts and failing to recognize that she's been encouraging his actions, the PT has played a role in creating an uncomfortable scenario.Ethical principles. The following principles of the Code of Ethics for the Physical Therapist provide guidance to Karen:Principle 4. Physical therapists shall demonstrate integrity in their relationships with patients and clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public.Principle 7C. Physical therapists shall not accept gifts or other considerations that influence or give an appearance of influencing their professional judgment. Author AfternoteI was most struck by one reader's response to this scenario. This respondent, a veteran PT, had been in position to observe a similar situation evolving between a younger PT and a patient. The younger PT had been oblivious to the patient’s escalating flirtations, so the older therapist took her naïve counterpart aside to describe the scenario as she saw it. This reader then urged the younger PT to diplomatically but firmly shut down any future attempt by the patient at overfamiliarity. The younger PT did so, the reader told me, and an uncomfortable and inappropriate situation soon was resolved. That account highlights the importance and value of colleagues who have seen something saying something — and of colleagues being open to acting as thoughtful sounding boards. A few other readers, in fact, reported having had opposite experiences. They themselves were at some point involved in a murky interpersonal situation with a patient, but when they asked a colleague for counsel, that colleague basically said "deal with it" rather than offering any helpful advice. While our guiding documents clearly state what constitutes ethical behavior by PTs and PTAs, the value of colleagues as interpretative intermediaries cannot be overstated.