In part 1 of this series I discussed three mistakes I made in my career using the biopsychosocial (BPS) model. If you haven’t already, check out part 1 HERE before you continue reading. In the second and final part of this series, I discuss four more.

4 – Not Setting Realistic Expectations From The Get-Go

Telling patients that they may not be pain free or make a full recovery is easier said than done. It’s awkward and there’s always the apprehensive feeling of “what if the patient doesn’t want to come back?” That being said it’s better to be realistic from the get go than have patients expect to make a full recovery and be upset when they don’t get there at the end.

It can also be a big problem when dealing with third party insurance providers (i.e. workers compensation, motor vehicle) when clients, for whom a full recovery may not be a realistic goal, expect therapy to continue and continue until a full recovery is reached. Plus, I’d rather be realistic from the get-go rather than have a patient drop off after 2 visits and say “oh Eric’s a bad physio since he didn’t cure me.” A few years back I realized that it’s a bit of a double-standard for us to blame doctors or surgeons who aren’t realistic with patients, yet not expect ourselves to do the same.

The way I go about goal setting occurs through two steps. During my subjective, I ask what goals a patient would like to work on in a more general sense (i.e. improved strength or flexibility, being able to return to a specific activity or do more of a goal activity) and then after my physical examination is done the goals are more refined.

If the only goal a client has is to be pain free I often follow it up by saying “if you were painfree what kind of things would you be doing differently?” I’m not anti-pain goals, but pain goals should be realistic and not be the only part of therapy. Having functional goals helps to stop patients (and practitioners) from “missing the forest for the trees.”

Some ways I communicate these findings are:

If it’s a client who will likely have a full functional recovery but may still have some pain I will say “I anticipate you should be able to do everything, or almost everything, that you want to do activity-wise. Your pain shouldn’t be overly noticeable and shouldn’t impact your quality of life.”
If it’s a client who will likely have both pain and physical limitations after therapy is done I often say “because of these factors (i.e. time since injury, psychosocial or physical health comorbidities, nature of client’s activities etc) I anticipate you will have an improvement in these area(s) but you may still have some pain or functional limitation.” While some may disagree with this I also like to aim lower in terms of goals.
If it’s a client who I think would leave upon being told that information I set very short term, “micro” goals as opposed to thinking longer term.

With some clients I also say “I can’t promise you that you’ll be the way you were before, but I also can’t promise that you won’t be either” as some clients (myself included) have made full, pain free recoveries after years of persistent pain. You never know until you get into it. Some clients aren’t going to be happy with anything other than a quick fix, and there’s not much we can do about that, but it’s crucial to set expectations from the get go.

5 – Sometimes Having Unrealistic Expectations of Both Myself and Patients

I used to be that guy that would beat myself up if a patient didn’t make a full (or even partial) recovery. That’s a common thing I see in a lot of young practitioners who are very passionate about what they do and want to help everyone. But the more I work and learn the more I realize how complex patients are and how many different factors can influence outcomes including:

Nature of injury
Time since symptom onset
Physical comorbidities
Baseline fitness or deconditioning
Psychosocial comorbidities
Personality factors & expectations
Previous care (and misinformation clients may have gotten)
Social barriers (i.e. work, family, hobbies)
Genetics
Just dumb luck

Once I got to the point where I was comfortable setting realistic goals and expectations with patients, I felt a lot of pressure and weight was lifted off my back. Don’t get me wrong – it’s still frustrating when you have a patient who isn’t progressing as intended or when you have a patient who expects a cure on the first visit. But now it happens a lot less often.

Having unrealistic expectations of patients can also be problematic. I would get frustrated if patients showed up late, didn’t do their exercises or would be doing a lot of the activities that beat them up. While these are all valid points it again comes back down to:

Is the program realistic for the patient?
Are the goals realistic?

If a 17 year old patient with shoulder pain works manual labour for 12 hours/day, you’re not going to have the same outcome as you would with a 17 year old with the same injury who is on summer break. The ability of the second client to consistently do rehab and manage load on the shoulder is much greater than that of the first. As such, despite the same injuries, the second client will likely have a better outcome. I used to feel frustrated with these patients but as I matured I realized that other components of their life may be more important right now. I accept that and work to make realistic goals and programs.

6 – Focusing Too Much on Pain and Not Function

This is a bit redundant from points 4 and 5 but is important to bring up as many providers and patients feel that the almighty 1-10 scale is the main (or even sole) indicator of progress. As I wrote about in my Failing Physiotherapy blog (1), it’s important to focus on progress beyond just pain or you may feel like you and your patients are going nowhere. It’s important to have functional measures of improvement that are relevant to the patient as well as time points to reassess outcomes and celebrate small victories.

7 – Taking on Too Much and Neglecting Self Care

I’ve wrote a lot before about how I made the following mistakes:

Not managing my own mental health and having to deal with stress, anxiety and depression.
Running myself into the ground (even with activities that I loved) and burning out.

As such, (and the fact that this article is over 1100 words already), I encourage you to read my article on my own experiences and lessons with mental health and self care (2). However, those mistakes pertain more to things I was doing, and feelings I was experiencing outside of my direct clinical work.

In my past job, I worked with an almost exclusive population of clients with persistent pain post-work injuries. Quite often the barriers to recovery that my clients’ experienced were either beyond my control (i.e. work barriers, psych/personality barriers, medical comorbidities) or were so deeply entrenched (i.e. excessive pain behaviours/guarding, maladaptive beliefs) that they were extremely difficult to change.

To this day, I genuinely love the staff I worked with and I’m extremely grateful for all they’ve done for me and for the lessons I’ve learned. However, I didn’t realize until I changed jobs earlier this year that I was emotionally and mentally running on empty and didn’t have the capacity to deal with a caseload of complex clients. I was stressed, burned out, depressed and didn’t have that “little something extra” when I needed it. When I switched to a general ortho/sports rehab setting, my mood and energy were 80-90% improved. It showed in my clinical care and outside of work.

When I did the online Cognitive Functional Therapy course earlier this year I remember Kieran O’Sullivan saying something like (and I’m gonna mess it up): “it’s fine to have complex patients but you need to have straightforward cases mixed in there as well, such as a routine ankle sprain or a wrist fracture that’s coming out of a cast”.

Bottom line – self care not only extends to what you do outside of work (good sleep, nutrition, exercise, down time and time with friends/family) but also to what you do inside of work (having a caseload demographic that is within your passions/interests and is also sustainable).

Wrapping Up

This was a tough series to write. It’s always tough for someone to publicly admit their mistakes, especially under the eyes of social media, but it’s important for me to share this information as I want professionals/students to learn this and hopefully avoid some of these pitfalls. I hope this article series helps you avoid making some of the mistakes I’ve made when using the BPS model.

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Biopsychosocial Approach: Mistakes I’ve Made – Part 2