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  • Writer's pictureKit Wisdom

Are we defining our patient's path too much?

Updated: May 1, 2020

How can we encourage healthcare practitioners to trust the patient has their answers?

Six months ago I met a lovely bloke called *Ben* who came to see me for recurring hamstring pain. He was an avid runner who, like many before him, was struggling with maintaining his love for running and the freedom it provided, for both his mind and body.

As a younger physio, I would have assumed the struggle centered on his inability to run, therefore my directed pathway for him would have been to restore his strength and function in order to help him 'return to running'.

I would have embarked on an exercise program that reflected what we 'do for hamstring injuries'.

Yet this was not the whole story.

Ben had been seeing a physio for his hamstring pain, yet felt he was not getting what he needed. When given space and encouragement to voice what this meant to him, he explained the frustration of his past experience. He described how he had been given a set of exercises to manage his diagnosed hamstring tendinopathy, and how every review session was about doing the exercises. They spent 30 minutes together every week doing exercises, with a directive of the same home exercises daily.

Ben felt it was not worth the investment of his valuable time and funds and described feeling like his full context as a human was not being taken into account. He commented, "I started to wonder if he was really listening to how I was going."

In that moment of story-telling, Ben had given me several bits of information worth noting. Importantly, he needed to tell his whole story of who he was - not just as a runner - but as a human pre-kids, a dad to one kid; then two, a husband, a busy manager of people, a competitive brother, a son to probing overseas parents, a lover of nature, a previous pain-experiencer, and a seeker of healing knowledge.

Secondly, and just as importantly, Ben communicated that he felt he had not been heard. He felt someone was listening but not really listening for what he needed.

Note to self: listen as you have never listened before!

When a space between stories emerged, I took the moment to validate Ben's need for exploring each person's pain experience specific to their context. What I mean by context really speaks to the question, "what does life look like for you?" Our personal context, or life landscape, can impact our mood, our nervous system's capacity, our motivation, our intentions, our everything.

Ben commented, "That's what I need. I need to fit this hamstring to my context, my life. Because running is a big part of my mental health."

I asked Ben what he wanted to get out of the first session together, rather than telling him what was going to happen. I find this question speaks to explicit autonomy and ownership building because it sets a tone of 'let's go where you want to go - and - I want to help you get yourself there'. He replied, "I want to understand the injury and how to manage it, I want to build my running load, and I want to do it all in a way that fits into the way I do life."

Note to self: this dude doesn't need me much, he wants a plan that he is invested in, makes sense to him, and he can seamlessly integrate into a busy life ... he's also very honest and transparent which is totes ace

Together, we unpacked Ben's life landscape on a (large) whiteboard, so we could map out all the different interconnecting parts. I like to consider 'life-load' from physical, emotional, cognitive, and mental health perspectives, so we can explore the wholeness of being a human.

Ben was a project manager within a busy, lucrative business with 14 direct reports. Work was high stress, enjoyable, and an environment where he sat for 5 out of 8 hours.

Note to self: work = go go go, managing lots of people = high cognitive load; sitting = once pissed off, tendons don't like compression

Interestingly, Ben learned through story-telling; he used it as a vehicle to help transfer knowledge with his team. So he felt comfortable sharing his story with me - it made sense to his brain.

Note to self: use story-mapping way to explain the treatment path

After work each day, he went to get the kids from daycare. Two boys, 4 and 2, needing rough and tumble interaction at the same time as compassion and care. Two glorious humans, who had hugely disturbed his sleep for the past four years, and significantly impacted his ability to exercise.

Ben related just how much having kids had changed his physical activity level. He could no longer just choose to run whenever he wanted, for however long he wanted.

Note to self: emotional load = life hectically changed from having kids - amazing creatures but also less freedom for self; physical = sleep shite - may well continue to be; mental health = way less 'me-time' = need running to be meaningful and feel competent in program

He needed to carefully consider his and his wife's needs around mental and physical health whilst caring for their kids. This meant having honest conversations around what they each needed and working as a team. At this point in time, that looked like two windows to run per week, one short and one long, and a social game of soccer - so any exercises had to be squeezed into free time that pretty much didn't exist.

Note to self: lots of responsibilities - less is more - choose only a few exercises - need bang for buck ....? use kids as weights - utilize fun/family/exercise time - need for more load - tendons want heavier (kids 20kg and 25kg); run sessions need to be able to build load efficiently but also gradually - need to keep him interested yet play the tendon long game

Enquiring about Ben's past history with pain proved really interesting. It gave me insight into his past running load, the centrality of running to his identity, his motivating competitive rivalry with his brother, the huge reduction of loading on his body since having kids, and how much fatherhood has changed so much of it all.

Note to self: really enjoying Ben's openness to questions surrounding his past - his ability to talk about his emotions and his reflective nature - remember to feed that back to him as a strength of his and use in follow-up sessions

Ten years ago he had been training for a marathon "in a smart way" with his brother providing both run-load programming and friendly antagonizing. One day he experienced an acute onset of sciatica. He couldn't move. He couldn't run. It took a long time for him to recover and when questioned more deeply, he reflected that maybe he felt he had not fully recovered as it was always in the back of his mind when running.

As he sat pondering his thoughts, I gave him space to sit in them. "Maybe I'm still conscious of it? Maybe it's impacting my pain experience now?"

Note to self: are Ben's beliefs around pain affecting his current hamstring pain? What is his relationship with pain? I need to be mindful of how I approach that with him - consider cognitive, emotional, mental health views; what questions will I ask to curiously enquire?

I took this opportunity to map Ben's running load on the whiteboard. By plotting out the increase in km's (external) and effort (internal) each week from his baseline load, along with when he felt a change in pain symptoms, we could see the sharp load increase and where his tendon was chucking a hissy fit. Plotting it visually helped Ben understand that tendons behave like toddlers when their load is rapidly changed (up or down). "Ahhhhhhh, that makes sense."

Note to self: map load visually for the plan going forward (learning);

talk about tendons like toddlers = he already has two! and laughter is the ducks nuts for shared communion, relating, trust, all the good stuff


As we started to head into the land of functional assessment for Ben and his hammy, I took a moment to remember the physio I once was. The physio who was scared shitless of doing it another way, that thought they had to stick to the absolute rules of subjective and objective land. That had to know all the tests, in a particular order; as a linear progression.

That version of me - that quite often went into a nervous system freeze response - to the shame of maybe not knowing. I remembered her and felt a kinship to her that I don't think I have really explored for awhile - for I sometimes fall back into that place where I feel I 'should' be getting better at knowing because I am older and 'wiser'.

Note to self: oi, can you hear your self-judgment? it's pretty bloody loud - how about you watch it and let it go? you're figuring out how to let it go remember? and you're doing a stellar job of that .. slowly slowly ..

One of the biggest game-changers for me as an evolving physio has been letting go. Letting go of thinking there is an answer. Letting go of assuming, expecting, and pretending that I am the one in charge. Letting go that the 'evidence' holds all the Truth. Letting go that I have to work in a particular way. Letting go of 'knowing' in the way we have been taught.

And stepping into a different way of seeing, sensing, listening, learning, exploring; maybe even a different way of 'knowing'.

It makes me wonder, is the way we have been taught 'to know' becoming more and more of an obstacle to patient autonomy and agency than ever before?

Are we trying to plot our patient's paths to maintain some sort of authority?

And is it becoming more and more an accelerant of health practitioner burnout, dissatisfaction, anxiety, and a lack of self-worth?

How can we encourage younger health practitioners to feel comfortable in the discomfort of exploring a different way of 'knowing'?

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