Communicating with Kids
Children can be scary.
I’m not talking about the teleporting dolls of horror movies – just regular pediatric patients.Some people have the natural ability to relate to children, and others might feel like they’ve been knocked out of their usual rhythm of patient communication. How do you explain pathologies to a 10-year-old? How do you make a personal connection, take an efficient subjective history, and get patient buy-in?
As a PT student during a pandemic, trying to practice pediatrics on baby dolls and my adult classmates, I’m curious. After all, somewhere in the world there is a scientist who has dedicated a significant portion of his life to studying kleptoparasitism in kangaroo rats (Kline et al. 2018). Surely someone in the research community has figured out how to talk to kids?
In their book, The Art and Science of Motivation: A Therapist’s Guide to Working with Children, Ziviani et al. emphasize the importance of empowering children by including their input and values in the therapy plan. Older children and adolescents especially benefit from selecting their own personal goals for therapy.
Here are some general recommendations from the authors for talking with children:
Verbal messages: Use words that the child will understand, depending on their age. Talk about how the child feels about the session and their goals. Use language that is “realistic, empathetic, encouraging and responsive”.
Nonverbal messages: Avoid using a “sing-song” voice, speaking loudly or overbearingly, and interjecting while listening. Instead, make eye contact with the child, and use a calm, positive tone of voice. Use facial expressions and body language to show that you are interested and enthusiastic about the session. Take time to listen to your patient and pause to wait for their responses.
Autonomy: Giving children choices and listening to their perspectives
“There are a few things you’ve mentioned you’d like to do; what do you want to do the most?”
“What do you think might happen if…?”
“How are you going to do it?”
Relatedness: Empathetic listening, feedback
“I understand…”
“It seems like this is hard for you….”
“Let’s see if we can figure this out together”
“Who can help you work on this?”
Competence: Affirm a child’s abilities
“Oops, it didn’t work out. Let’s think about other ways/strategies”
“What skills will help you to do it?”
“What will make you feel you can do it?”
I’ve summarized some general recommendations from Ziviani et al. by age:
Age 4: Try to match the child’s sentence length (avg. 4 words). Listen for descriptive words that the child uses and incorporate them into how you describe the therapy. Respect the child’s desire for independence. Understand that these children will become frustrated easily if they cannot accomplish a goal.
Age 5: Offer choices, and help the child find words for their emotions.
Age 6: Adult expectations influence the child’s self perception. Ask the child for explanations or directions, and ask about their feelings.
Age 7: The child describes personal experiences and understands 5-step directions. Use complex tasks and mirror the child’s developing gestures.
Age 8: The child is beginning to compare themselves to other children and seek social acceptance. Involve child in goal planning discussion and peer engagement.
Age 9-10: Use humor to make therapy more interesting.
Age 11-12: The child is developing responsibility and self-reflection. Encourage them to think about their behavior, thoughts and emotions, and to take more responsibility. Here are some specific phrases that Ziviani et al. suggest using. They are tailored to three psychological needs of a child: Autonomy, Relatedness and Competence (ARC).
We all want to feel like we are making choices in our care. We want to feel heard, and we need genuine encouragement. Kids need the same. There’s no need to fear.
References:
Kline MP, Alvarez JA, Parizeau N. Kleptoparasitism of Harvester Ants by the Giant Kangaroo Rat (Dipodomys ingens) in the Carrizo Plain, California. Western North American Naturalist. 2018;78(2):208-211. doi:10.3398/064.078.0212.
Cuskelly M, Poulsen AA, Ziviani J. The Art and Science of Motivation: A Therapist’s Guide to Working with Children. Jessica Kingsley Publishers; 2013. pp. 159-182. Accessed October 8, 2020. https://search-ebscohost- com.libproxy.unm.edu/login.aspx direct=true&db=nlebk&AN=509756&site=ehost live&scope=site.
Telehealth during Covid- from a patient’s perspective.
Over the past four months or so I have had the opportunity to see healthcare during the COVID-19 era from the perspective of a patient. This has allowed me to personally feel how the changes we have made to keep providing patient care during a global pandemic have impacted our patients. This opportunity has allowed me the chance to see the good and the bad of telehealth and social distanced health care. To begin I want to start by saying all the health care providers I have worked with have been wonderful and are all phenomenal providers, and second this is only my perspective and is not meant as a fully encompassed view of the current state of health care.
I wanted to start by stating how weird it is to go into potentially life changing appointments while sitting at home and staring at a computer waiting for the doctor in the virtual waiting room. The setup just feels a bit odd, one minute you are sitting there drinking your morning coffee in your PJ pants and then all of a sudden you are in a deep virtual conversation with a provider about information that changes the trajectory of your day to day life. Before you know it the zoom, or google chat room closes and you are left sitting there trying to process the news in your living room. The good news is many doctors have understood this concept and are willing to sit in the virtual chat and discuss details for as long as you need, however the difficulty with this is that there is always an abrupt ending to the call and the patient is still left sitting there with their mind racing and the urge to google what they were just told. One thing I have found that has helped is that when a doctor gives life changing information many of them have allowed me the opportunity to schedule an in person visit after the virtual call to follow-up and do the physical examination.
Another area that has been interesting to see is that there seems to be no set appointment length with patients during this time. My experience has been that my virtual appointments last anywhere between 6-45 minutes. This has been an adjustment as a patient because many times you go into physical appointments and can expect to be seen for around 20-30 minutes. My best virtual appointments have been with the doctors that take the time that would normally have been filled with physical examination and discussed research and things to try at home and scheduling in person visits as necessary. My less effective virtual appointments were doctors just telling me physical lab results that have already been uploaded to my patient portal and ending the call with no clear conclusion. As many professionals try to navigate this new era of health care one area that can not be lost is bedside manners.
One area that I have enjoyed about being a patient in this time is that it has expanded the network of clinicians I can see. I was able to see my PCP back in Minnesota, while still going to school in New Mexico and then within the same week see a specialist down in New Mexico. This type of care has allowed for a wider variety and a larger network of providers to work together. It makes it feel almost like you have your own personal pick of providers as long as they are covered by your personal insurance. This makes getting second opinions easier and more efficient than before.
Telehealth has provided many challenges for providers to work through on their end, but one area that can not be forgotten is the patient’s experience. The struggle of having to log into a virtual chat to hear news that could alter an individual’s whole life and having that chat end leaving them sitting in their living room is unprecedented for many individuals. Having had the opportunity to live this reality has made me recognize the struggle our patients are going through. The lack of face to face interaction has taken a piece of the compassion out of a professional field that strives to provide our patients what they need during major life changes. This isn’t to bash on telehealth. I have actually thoroughly enjoyed being able to utilize telehealth as a patient, it is just to remind ourselves that our bedside manners are even more important when social distance creates barriers to the compassion that many of our patients need. Through our own continuing education and experiences I think telehealth can become an important piece of health care going forward.
Treating the Whole Patient.
Treating the Whole Patient.
The noncompliant patient who convinced me to study PT
We didn’t do any therEx. It was, in a way, the least physical physical-therapy appointment I’d ever seen.
But it was this appointment that opened my eyes to the profession and convinced me to go to PT school.
I was shadowing at a physical therapy clinic for the first time. I watched appointments quietly, worried about getting in the way, and asked shy questions. This patient arrived for her follow-up appointment late. Her face was flushed and she talked quickly, spilling out every inconvenience of a bad day, her general frustration with the medical system in general and several nurses in particular. She didn’t understand her radiology report, no one would explain it right, they said she was taking up too much of their time, she was running late, it was too hot out…
The PT nodded along, then gently mentioned the HEP.
Now the patient looked as if she was going to cry. She hadn’t done it, she didn’t know if there was any progress, it was so warm in here…
My mentor asked if the patient would like to use the session for soft tissue work, ultrasound, and looking at the radiologist’s report together.
The patient finally stopped for breath.
After some quick gross motor tests, we went back to a private treatment room, where the PT gave manual therapy and ultrasound, and listened. She gently offered perspectives (“you know, it’s likely this person didn’t mean it that way…”). She summarized the radiology report in a few sentences, and the patient immediately accepted it (“See, why didn’t they say that?”). In the end, the PT reassigned the previous HEP, and the patient left calm, breathing deeply.
After she left, the therapist saw my puzzled face and quietly told me some previous conditions in the patient’s history to explain her emotional instability.
I left, thinking.
The patient had a distorted view of pretty much everyone she talked about. She complained about other medical professionals, she was impatient with people in general. But she was convinced that the therapist was on her side. The therapist cared.
One of my classmates says that they were inspired to pursue PT when they realized how physical therapy treatment helped them “mentally and not just physically.” This is similar to my own motivation. This appointment was one of the first times I realized the wonderful opportunity PTs have to treat a whole person – to come alongside people who are hurting or frustrated or just have questions, and to be on their team as they heal.
I know I’m preaching to the choir – if you’re reading this blog you’re probably a healthcare provider and you know what an influence a person’s emotional health can have on their success in therapy. But I’m hoping that the story can encourage you when you are teaching students. We learn more from watching you than hand positioning for goniometry. We see you motivate patients to push on and achieve their goals. We see your compassion, and the ways that you carefully gain a patient’s trust. Soldier on! We’re learning from you.
The Importance of Language in Your Practice
The Importance of Language in Your Practice
by Jonathan Lewis, SPT
In school, you will be exposed to a vast and alien vocabulary composed of similar words that denote important distinctions: cerebrum and cerebellum, optical and ocular, eccentric and concentric, ligament and tendon – literally thousands more. And it doesn’t end with just the simple terminology. As you learn the lexicon of your new profession, you must also start integrating these terms into a nearly endless alphabet soup of acronyms. Knowing this shorthand – PICA, CSF, PNF, DM1, BP, PRICE, on and on – will become vital for your ability to be able to quickly and concisely communicate with your fellow students, clinical instructors, and professors.
Developing an ease with the vocabulary and its shorthand will pay off in a lifetime of effortless communication with other medical professionals. Additionally, maybe the most important aspect of becoming comfortable with this peculiar vocabulary is in the valuable seconds you will save when “charting” during your rotations. And speaking of rotations: you will find that any clinic you work at will have a culture that has developed its own argot to describe patients and procedures – slang terms that will have little meaning to anyone outside of that clinic.
It’s easier than it sounds, though. Your mental library of medical jargon will become effortless as you become immersed in reading studies, presenting papers, and cramming anatomy terms. However, the real trouble with using this newly acquired language – and the most difficult part for some new practitioners – isn’t in learning it. It’s turning it off.
When you’re in clinic, you might find yourself telling a patient that you’re going to “perform an HVLA manip – specifically a TJM – to treat their LAS.” You’ll be met with a blank stare. So perhaps you’ll change your approach. You might simplify your language and nonchalantly tell the patient that you’re going to “perform a maitland grade 5 manipulation on their talo-crural articulation and hopefully they’ll feel some relief following the cavitation.” That probably won’t help much, either. If your CI is kind, they will take pity on you and interject: “She’s gonna pop your ankle. Research shows that this helps with ankle sprain recovery.” You’ll wonder why you couldn’t say that – it was a simple, true statement that everyone involved could understand.
Don’t worry, we all do it. We spend years learning that language is important – A’s quickly turn to B’s or C’s on anatomy exams if we use ligament when we should’ve put tendon or vein when we should have put artery. This is for good reason though – we don’t lose those points because our professors are mercurial and censorious academics that love to make us suffer (although, it will feel like it at the time). Instead, it’s to teach us that, in this profession, specificity is essential.
The devil, we often hear, is in the details. And, for physical therapy students, our ability to accurately describe the details and recognize the distinctions is tested and honed every day during our didactics – and this is important. Picking up on the difference between, for example, referred visceral pain and skeletal-muscle pain is one of the reasons we will someday proudly call ourselves Doctors of Physical Therapy. Our ability to be specific allows us to differentially diagnose and refer patients – but it has the side-effect of developing in us the habit of using terms that very few outside of the medical community will understand.
This is why we need to practice switching gears and language often. This is why we need to look for the moment our patient’s eyes start to glaze over and adjust our language. The best therapist I ever shadowed used words like “ouchie” and “bum” with her patients. Her ability to communicate incredibly complex concepts to people of all backgrounds while still being a precise evaluator was amazing. However, this skill was something she had to learn and practice.
Our professors ask us to “avoid jargon” with patients and we attend lectures on the importance of medical literacy and access for all populations. However, after years of being immersed in the language and culture of the medical field, talking like a medical student is a tough habit to break.
However, to be a truly effective practitioner we need to break it. My advice? Start practicing from day one. Use the terminology with your peers and professors but when you’re speaking to people outside of the discipline, ask yourself “would I have known what this meant a year ago?” If not, see if you can adjust your language to increase understanding between you and your interlocutor without losing the meaning of what you’re saying.
This practice will pay off when you get to your first rotation, I promise.
August 2017 bestPT Newsletter: Persisting Problems with Leftover Prescriptions
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August, 2017 Newsletter
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6 New members joined bestPT in July 2017. Each new member benefits from and contributes to our network strength.
Let’s welcome bestPT newest members!Samantha Monahan of Bassett Physical Therapy, Stanleytown, VA Sopia Polanco of Bit-By-Bit, Fort Lauderdale, FL Christa Johnson of Comprehensive Hand & Rehabilitation Waterford, MI Shalaina Russell of Kalispell Rehab, Kalispell, MT Michele Kurkowski of Kiwi PT, Highland, MI Norma Garcia of Two Trees Physical Therapy & Wellness, Ventura, CA |
Looking at the landscape of physical therapy practice management, we see a playing field tipped to benefit the payers and hurt the provider. The relationship between payers and providers is adversarial, but billing networks offer solid strategies that allow providers to get back into–and win–the game. The “network effect” allows a large number of unique providers to capitalize upon their strength in numbers. Please help us strengthen that network. | |
 | If your friend schedules a demonstration of the system, we’ll send you a $25 Amazon gift card! |
 | For each friend that you refer that joins our network, we’ll credit you $50 each month the office is contracted with us through the first year! |
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July 2017 bestPT: PTA, the 1st choice for a 2nd career
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 PTA: First Choice for a Second Career Many PTAs began their work lives in other occupations but have come to find a home in physical therapy. While their individual reasons may vary, many of these professionals are resuming their studies as older students focusing on a second career that is more satisfying than the work they had previously done. Work that is emotionally fulfilling, stimulating, varied, all the while being educationally affordable and serving a hot job market. (by Eric Ries, at PTinMotion)
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6 New members joined bestPT in June 2017. Each new member benefits from and contributes to our network strength. Let’s welcome bestPT newest members!Lauren Sahagian of Big Sky Pediatric Therapy, Austin, TX.Colleen Lafferty of Bit-by-Bit, Ft Lauderal, FL.Sarah & Linzie Schwindt of Health Rehab Solutions, Kalispell, MTAdrienne Martinez of Prime Therapy & Pain Center, Riverside, CA.Bruce Wihongi of Kiwi Pt, Highland, MI |
June 2017 bestPT: 10 Easy Ways PTs Can Promote Fitness
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10 Easy Ways Physical Therapists Can Promote Fitness
This extra time gives physical therapists (PTs) the opportunity to do more than help patients heal from injuries and regain mobility–they can also help them learn to pursue wellness, achieve greater fitness and possibly avoid injuries in the future. And we’re not just talking about sports physical therapy. PTs can work with all patients to help them achieve the optimal fitness level for their level of ability.
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Unlike many medical providers, physical therapists have ample time to talk with patients, to learn about their lives and to educate. Welcome New Members to the bestPT Team in May7 New members joined bestPT in May 2017. Each new member benefits from and contributes to our network strength. Let’s welcome bestPT newest members!
Ingrid Cruz and Gordon David of Prime Therapy and Pain Center Riverside, CA. www.primetherapy1.com/ Jeanne Cunningham and Lisa Dennis of Big Sky Pediatric Therapy, Austin, TX. www.bigskyfriends.com/ Christopher Leck of Health Rehab Solutions, Kalispell, MT. www.healthrehabsolutions.com/ Amy Adler of Bit-By-Bit Therapy Fort Lauderdale, FL. bitbybittherapy.com/ Jennifer Huyser of Northland Pediatric Physical Therapy, Pleasant Valley, MO. www.northlandpediatricpt.org/ |
Five ways technology is improving the physician-patient relationship
Few things are as perplexing to healthcare providers as the challenge of nurturing more meaningful, intimate relationships with patients in an era of rising healthcare costs. Vendors have rolled out a number of healthcare technology solutions to address these challenges, such as app-enabled patient portals, but much of the time, these tools simply serve as data repositories — underutilized by both the patients whom they are intended to serve as well as the physicians who are supposed to be using them. However, some physicians aren’t hesitant to adopt technology. |
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