There is a solid chance you’ve heard the phrase ‘trust your gut.’ As a rehabilitation professional, you probably know when there’s something *not quite right* with your patient. It’s our job to be an advocate for the patient, and to communicate our concerns to the physiatrist and attending physician. But how can you make sure that your concerns are communicated well, and acted upon?
Unfortunately, many of our colleagues (and probably ourselves) have been put into this uncomfortable position. How do you advocate for your patient, and not only be heard, but be actually listened to (and taken seriously)? Consider the following five points to assist you with communicating your concerns effectively.
Having a “bad feeling” just is not enough to justify further diagnostic testing, stat lab draws, or even a transfer to the acute care emergency department for further evaluation. As a rehabilitation clinician, you need data to support your therapeutic interventions, goals, and recommendations and you also need it when communicating a change in status to the physician.
You may be asking yourself, “What kind of changes do I need to observe? What is considered significant?” Something to keep on your radar is increased weakness. If you notice that your patient has increased weakness, especially on one side of the body it could indicate a new (or evolving) CVA or other neurological issue. It is likely that if a patient is experiencing increased weakness, their functional status will also change, meaning their transfers may require more assistance, they may not be able to ambulate, and their ability to perform ADLs will also diminish.
Something else to take notice of would be a change in the patient’s speech and language. If a patient is noted to have an increase in slurred speech, or an increase in word finding it could indicate an acute neurological change.
You may also note a change in the patient’s ability to swallow and their ability to feed themselves to go along with the change in communication abilities. A change in cognition is also something to be attuned to.
An increase in overall confusion can be indicative of a brewing infection – most often a UTI or something like dehydration. It would be beneficial to check the patient’s most recent lab results, and recent record of food/liquid intake. This is especially important for patients on altered diets as there is a known link between thickened liquids and dehydration.
There are, of course, a lot of other changes that can take place with our patients, but the ones mentioned are some of the most common ones that pop up.
Re-administering some assessment items to illustrate a decline in status is also helpful in building your case. For example, the Orientation Log is a 10 point serial assessment of orientation for anyone who is confused. The Orientation Log can be used to document progress, or decline, from day to day. Read more about the Orientation Log, and its uses, here.
For example, if you approach the physician, and indicate that your patient scored 25 points out of a possible 30 points on assessment, but is now scoring 15 points, it presents a clearer picture when discussing the patients decline in status. Saying “I think they are more confused” is not going to help your cause – we could ask ourselves, “do you THINK, or do you KNOW?”
We want to be the best advocate to our patient that we can be, and skilled documentation is a huge part of this.
Documenting concrete functional changes in your daily note (regardless of how large or small), as well as keeping some notes for yourself are going to be helpful when pleading your case to the physician. If you work in a facility or setting where daily notes are not required (believe it or not, they do exist) start writing a daily note in the chart where applicable.
Do your best to paint a picture of the patient’s current functional status, and functional decline. Also document any interdisciplinary team communication regarding the patient’s status, including any communication with the physician(s) you may have. You need to remember that if you did not document it, it did not happen. CREATE THAT PAPER TRAIL.
Further improve your communication by reading: 5 Things to Think About when Educating Caregivers.
Look at the big picture – is the patient having increased difficulty or a functional decline in other disciplines? Communicate with your fellow team members – other therapists, nurses, and allied health professionals (respiratory therapy, registered dietitian, nursing aides, therapeutic recreation etc.) and see if they are noticing the changes that you are noticing. Has there been a functional decline during their sessions, or interviews? Has the patient’s nutritional intake declined? Have they needed more oxygen support during the day or overnight? Do they need more assistance with activities of daily living, or are they now incontinent?
Ensuring that the entire care team is on the same page is going to be key when approaching the physician with your concerns. If the decline seems to be only specific to your discipline, take a step back and look at what you’re doing – maybe you changed the way you are cueing them and don’t realize it, or maybe the time of day you’re scheduled to work with them is impacting their performance.
EMPOWER THE PATIENT
Talk to your patient and ask them how they are feeling if they are able to accurately and effectively communicate with you. Make them part of the conversation about their care. Remember: it’s THEIR plan of care, and you can also help the patient advocate on their own behalf.
Encourage them to communicate with their physician(s) about how they are feeling, and what they are noticing. More often than not, patients do not want to ‘bother’ the physicians because they feel they have more pressing issues and other patients to manage. We need to empower our patients to speak up! Their physician cannot help them if they do not know what is wrong. Also, as therapists, we traditionally spend more time with the patient then the physicians do, and patient may be more inclined to speak with us about their concerns then the physician. It may be helpful to be present (if you are able) when the physician rounds on the patient to help facilitate the conversation between the patient and the physician about what items have changed for them over the course of their care. Your presence can help give your patient the confidence to advocate for themselves.
You have done your due diligence, and you have all of the concrete evidence you need to approach the physician(s) about a change in your patient’s status and condition. Now, as satisfying as running, yelling, and waving your hands at them would be, you cannot take that approach if you want to be taken seriously!
Monitor your tone, rate, volume, and body language. You don’t want to seem accusatory or rushed, but you do need to communicate confidently. This seems silly to some, but you need to be professional as possible when communicating your concerns. Use good eye contact, professional jargon, and monitor your volume, rate, and tone. Not all physicians may be receptive to concerns, and some still feel that things are only a problem if they recognize them as a problem. You cannot control how someone is going to receive your concerns… you can only control how you present them. Some great tips on improving your overall communication skills are here! Check it out for a list of 10 items that can assist you with being an effective communicator.
Demonstrating solid clinical reasoning skills and good communication skills will help you build trust with your facility physicians. The more your physicians trust you, the more likely they will be to take your concerns more seriously when they arise. Being proactive, demonstrating active listening, and being open to their suggestions will also assist with building a solid physician/clinician relationship. At the end of the day, we’re all here for the betterment of the patients and we can’t take things personally if the physician does not go with our particular recommendation.