Shared Decision Making on paper sounds so easy, but in practice it requires massive and constant humility to let go of control and listen with authenticity to my patients. A much wiser PT once said to me, “Try to care for your patients like they were your only child, and strive to teach them to be so good at self-management that they never need you again!”
Shared Decision Making also means reflecting on my thoughts with my patient. This is not a new concept; all good clinical reasoning involves reflection. But when I do this, I find myself sharing my patient’s narrative interpretation of the problem (and not just listing findings). Shared Decision Making involves transparency about misunderstandings and exposing both of our belief systems that often become a roadblock to recovery. All of this creates a closeness with my patients that I never expected. Not only are these the attributes of advanced practitioners, as evidenced in many research studies, but they also contribute to the most enjoyable way of practicing as a PT.
Patients come to physical therapists with their stories of pain, a loss of self, and a sense of despair. It is my job to simplify the problems and rewrite those narratives into stories of hope and health.
Molly is one of my favorite humans and an elite rugby player who had also played collegiate-level soccer. She would say that she is “moving stubbornly toward the end of her career,” but not without a fight. Molly came to me for help with a chronically painful — and worsening — right shoulder.
Molly’s first goal was to play at the upcoming touch rugby World Masters Games in Australia, and her injury was limiting training time. She had been advised to quit training and get surgery. This was not OK for Molly, and she wanted to tackle this problem head-on. My priority as her physical therapist was to see if that objective was possible, and if so, how I could help her accomplish that. What became apparent to me was that her second unspoken goal was to continue to be an athlete and win another battle, this time with her body.
Her physical presentation upon initial evaluation was typical for a high-impact sport like rugby. Recurrent trauma had taken its toll. Frequent episodes of partial dislocations with ever-increasing pain, secondary sites in the neck, and now a further complication with a high ankle sprain. The most recent shoulder injury led her to a physiatrist and MRI imaging that revealed a SLAP lesion (a tear in the shoulder arm socket) with a partial thickness tear of the Supraspinatus (the muscles on the back of the shoulder). Frequent accounts of pain, apprehension, and weakness started to match the imaging. Practically speaking, Molly was unable to dive fully with an extended arm, take heavy hits, or win the grappling challenges as she was previously accustomed to do. Her unfamiliar and unexpected cautiousness was a focal point of our first examination. She was unclear what path to take, and this impacted her sense of self-confidence and her physical and emotional resilience. She remained typically tough, but scared. Molly was about to teach me an unexpected way out of this paradox.
Lesson two: Shared Decision Making sometimes means taking a calculated and mutually agreed upon risk
Over the course of the next two months, Molly and I created a new plan for the rehabilitation of her shoulder. However, the most important breakthrough was having me step away from trying to be in charge and letting Molly lead the charge with a new, almost risky approach. She looked into the possibility of a series of stem cell injections. This turned out to not only be a helpful boost in decreasing her pain levels, but it also gained three to four months of strengthening that she would not have had otherwise. We moved briskly away from a reliance on passive care and pain avoidance to a more active focus that included hitting benchmarks. We added a lot of hard mid-range stability into a tough workout that she could do painlessly. We also lined up massage and acupuncture to reduce the stubborn protection in her muscles, spinal manipulations from a Chiropractor friend, and coupled it all with a smorgasbord of partnered sport-specific stability exercises. All of this made me realize that Shared Decision Making is not between two people but among an entire village!
The results have been better than either of us thought possible and are on-going. This story doesn’t have a fairytale ending, but it is a solid result that Molly owns and is proud of. She has a new skillset in self-management and has become better at early active care, so much so that she can put me out of a job pretty soon.