Patient-centered care orients around the patient. Which seems like a good thing. Except, it could also be individualistic, pathologizing, and remove accountability from the therapist, their relationship and social factors.

It may be convenient for us to think that physiotherapy is just about the patient, and not us, but that’s naïve.

We are impacted by all our relationships; personal and professional. We impact our patients,  and they impact us. And that doesn’t mean we’re not boundaried or unprofessional, it means we’re human physios, not robot physios.

We are 100% in the picture and we are as relevant as the patient to the dynamic and outcome. Perhaps even more so as we inherently have more power in the room.

So, we can say we’re making it about them (patient centered care), but that is filtered through

• Who WE are
• What WE think
• How WE’RE biased 
• How WE feel emotionally
• How WE feel physically 
• How WE react to this type of patient/person
• OUR comfort and confidence with the topic in hand 
• Etc etc etc – this list literally doesn’t end

That means that ‘patient-centered care’ is actually an interpretation of the patient’s needs that is filtered through us in terms of..

• How we have assimilated (often judged and compartmentalized) the information from the patient 
• Any limitations based on our habitual thinking
• Any limitations to our ability to feel and empathize with them
• Our particular knowledge base 
• Our particular bias and needs 
• Our ability to be present and connected to them in that moment 
• Our ability to be open and curious to what doesn’t fit into our box of knowledge and understanding

And – bad news for all the perfectionists out there – we can’t change this.

It is, again, just being human.

 Imperfect, but real.

And really useful imperfection when we’re mindful about it.

What we can do is acknowledge ourselves as central to our processes with the patient.  Consider this ‘relationship-centered care’.

What is relationship-centered care?

The relationship being everything, conscious and unconscious, that passes between you and the patient. Often termed therapeutic alliance. Both what you’re cognitively doing as part of your physiotherapy practice, and all that’s unconsciously present from you as a person and professional. And the same from the patient.

Bringing relational awareness central to our approach doesn’t give it any more power or relevance, it’s already dominating the outcome, it just makes it ACTIVE rather than PASSIVE.

We need to be aware of HOW we interpret, connect, react, bias, feel, etc. What’s happening in the interaction, from cognitive, to emotional, to physical components. 

I love the phrase

“Name it to tame it”.  Dr. Dan Siegel

When we’re completely naïve and in denial of ourselves in relation to our patient, we have no idea how much our unconscious is ruling the show, and sometimes how much havoc it’s causing. Eek. 

So how does this show up in practice?

Let me ask you a question – do you have a particular type of patient that you find harder to connect with and treat? 

Perhaps patients that are really cognitive and defensive?

Or those who are really emotional and ‘needy’?

Or perhaps you connect with athletes better than chronic pain patients, or women better than men?

Do you think this is about them?

NO!

It’s about you! 

Do you think that your ‘patient-centered care’ has the same quality for those you connect with than those you don’t connect with?

No.

The goal of patient-centered care, as far as I understand it, is to make treatment the best it can be for that particular patient.

No cookie-cutter approach.

It means they have a say, they have consent, their goals drive the process and their preferences and values are adhered to. And that’s awesome.

But.. this process could still occur with the therapist

• retaining their position of power
• being didactic
• using lecture-based education to gain consent
• asking the right questions based on psychosocial factors, or giving out an outcome measure…
• but not really connecting with the patient.

The consequence of this, is the potential objectification and pathologizing of the patient. It still makes the patient the problem that the therapist is trying to fix.

Patient-centered care ignores that therapeutic alliance is the relationship between 2 people, equally driven by and impacted by both. 

Who the therapist is, and how they show up, is as relevant as who the patient is and how they show up. Both in terms of process and outcome.

This approach requires the therapist to disconnect from themselves. Leave themselves at the door.

(Although FYI they’re not really – it’s just their own lack of awareness)

When they do that, they can no longer monitor, discern, and regulate how they are impacting the interaction. 

The therapist is in DOing mode, rather than BEing mode.

So now we have an objectified patient AND an objectified therapist.

It’s not mean, or intentional, it is just how we’re taught to treat and educate in our society (from a disconnected ‘doing and fixing’ place).

So how to be more consciously relational?

If we practice treating from a ‘being’ place, and get to know our own intricacies and how they show up at work, we can become conscious of how we’re relating and its impact on ourselves and our patients. 

From here, we can ‘do’ much more mindfully. Because ‘doing’ isn’t a problem – it’s required of course.

But all ‘DO’ and no ‘BE’, that’s an issue.

What this means is we need to enter the treatment room mindfully and completely.

We consciously connect to ourselves, AND the patient.

We acknowledge that it’s a reciprocal process.

We come off our pedal stools.

We acknowledge our authority without retaining power.

We’re humble.

This makes for a much better therapeutic relationship. A more authentic, real, and honest relationship.

It’s more vulnerable, which can be harder at first, but more liberating in the end. (Perhaps I’ll write more on my journey with this soon). 

And.. As I’ve realized with a deep dive in this amazing year for learning. It doesn’t end there. 

The problem with individualism

Patient-centered care, to go on about it a little more, is super founded in individualism. Which ignores the collective.

We can’t ignore all the social, cultural, political, and historical factors that have influenced the therapist ending up in the therapist’s chair, and the patient ending up in the patient’s chair. 

So, now let’s imagine we’ve become more relationship-centered.. how to be more socially, racially, and culturally mindful. 

As well as us as therapists, there are many other invisible strings that are pulling on the patent’s potential.

The individualism of patient-centered care is great in terms of a bespoke approach, but unfair in terms of putting all onus and focus on the individual.

I know patient-centered care looks for and acknowledges social factors. But in my experience, it still does this in terms of ‘fixing the patient’ in terms of this. Or having the patient take action to ‘fix’ this.

Often, they don’t actually have the autonomy to fix many of these variables. It’s out of their control, and certainly not their fault. It’s much bigger and broader than whether they ‘have support at home’ and are ‘happy at work’.

And we don’t operate and heal disconnected from the world around us. 

Just because we can’t necessarily change this, does that mean we just ignore it and assume poorer outcomes for marginalized folk?

What can be harmful is treating a patient as independent of these factors. (Not fully acknowledging them).

That’s basically doubling down on the oppression. Ignorance is convenient to the oppressors, not the oppressed.

In physio, what can be particularly harmful is ignoring how the medical system may have historically (or presently) been damaging to our patients.

It can be easy to disregard these factors if we haven’t experienced them ourselves.

It can also be easy to disregard them if we don’t feel comfortable having a dialogue around them.

But, know that these factors are deeply real and obvious to the patient. And our ability to go there will massively impact our relationship and ability to connect.

What does social awareness mean in practice?

Do you think a white settler therapist could have an authentic therapeutic alliance with an Indigenous person if they are totally naïve to the injustice experienced by them in the healthcare system, both historically and today?

Or might the Indigenous person have to bend to meet the white therapist’s ideas, beliefs, and perceptions around healthcare? 

Even if the treatment program was based on their goals, you educated them on their problem, and informed consent was obtained, how ‘patient-centered’ is this? Or is it more ‘physio’s limited perception of patient-centered’.

Do you think if this impact was understood and acknowledged by the therapist – the acknowledgment that it’s NOT just the patient under the microscope but there are SO many other complex factors at play too? Would the relationship be more authentic and connected?

Please think yes. 

Maybe, “socially conscious care” is another good phrase.

Let’s think big

Imagine the therapist knows their flaws. Knows their bias and limitations. Knows how to let go of their own agenda in the room (diagnosing and getting treatment right).

And instead was self-aware, humble, and curious. The therapist used the same skill set and expertise but in this totally different approach, open to the patient leading and them following.

“Patient lead care” maybe?

Let’s say the therapist understands that there are historical and social factors that will be playing into this patient’s belief system, experience, and access to care.

Let’s say that the therapist understands their own privilege, as well as their own flaws. 

Imagine if the therapist could be aware of and connected to all of these things at the same time.

What kind of experience could that open up??

I’m telling you, not only is it better physio – it also feels really good :)