The Changing Patient Conversation
Managing patient expectations when technological advancements stir patient desire for the latest state-of-the-art device.
Talk-show host Katie Couric interviews a woman who writes in cursive with a bionic hand. The evening news shows Boston Marathon bombing survivors at a running clinic wearing the latest running legs and feet. A You- Tube video shows a U.S. Army veteran walking freely while using a sensor-controlled KAFO.
These are encouraging, heartwarm-ing stories that can be hard to view objectively, especially if you're someone who recently lost mobility due to injury or disease. As the technological advances in The O&P industry have rapidly expanded, so has the media attention, fueling a desire for O&P patients to seek the latest and greatest for themselves. "Patients come in a lot more educated now," says Trevor Townsend, CPO, Valley Institute of Prosthetics and Orthotics, Bakersfield, California. "They've had their amputation, they go online, and they see someone doing things with a specific prosthesis, so they come in and want that. They didn't use to do that."
With all the excitement about microprocessor-controlled knees (MPKs) and bionic hands, it can be a challenge for practitioners to help patients sort out the options, especially when patients come into the office already emotionally invested in certain products-products that may not be right for their situations. And, with Recovery Audit Contractor (RAC) audits becoming the norm, practitioners have to be sure that every MPK, for example, fills a measureable need and is not ordered just because a patient wants one.
Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics, Hanger Clinic, headquartered in Austin, Texas, says it's important to be honest with the patient but with sensitivity. "You don't want to be negative, and you don't want to let the patient down," Carroll says. "We're all for keeping the patient encouraged. But when we discover a product is not in the patient's best interest, we have to be subtle in how we explain that.... Because if they're all excited about it, you can't just say, 'No, it's not for you.'"
Begin by Listening
Angela Montgomery, CPO, practice manager at Hanger Clinic, Boulder, Colorado, says the conversation begins with listening. The characteristics of Boulder and its residents, a college town which tends to have a higher than average median income than found nationwide according to U.S. census data, and a proliferation of high-tech industries, affect the perception that many of Montgomery's patients have prior to visiting the practice.
Montgomery says many of her patients have doctorate degrees and have already read the research before they come to her. "I don't just throw their ideas out the window," she says. "If I'm dealing with a mechanical engineer and they have an idea about the way a foot should function, I'm going to listen to them because they probably know what they're talking about. And, selfishly, I benefit a lot from just listening to these people."
Even if the patient hasn't read the research papers, Townsend says, it's still important to listen and try to accommodate the request. "I try to listen to my patient as much as I can," he says. "I think if you're too close-minded to what the patient wants, then you're not going to have as good an outcome. Engaging the patient in the selection process is a huge part of what we do now."
Wendy Beattie, CPO, FAAOP, facility manager at Becker Orthopedic, Waterford, Michigan, concurs. You can't just read the patient's chart and make a recommendation. The best solution, she says, is one that satisfies the patient's needs and their desires.
For Mark Muller, MS, CPO, FAAOP, an instructor with the California State University, Dominguez Hills (CSUDH) Orthotics and Prosthetics Program, Long Beach, a matter-of-fact discussion of the patient's needs and goals is a logical way to begin the conversation. "Whenever someone comes into us with a clipping from a newspaper and says, 'Hey, I want to try out this new knee,' we ask, 'What are your actual needs for this? This particular knee can do these things. Is that part of your goals?'"
Carroll takes the conversation a step further with a dialogue on needs versus wants. "I want a Ferrari," he illustrates. "Do I need a Ferrari? No. With a prosthesis, it might be, 'I want that thing I saw on television last night.' And I might say, 'Why?' That's when we get into the discussion of wants versus needs.... I might be watching a patient walk on a mechanical knee and with every step I'm so scared that they're going to fall and injure themselves. That person needs a microprocessor knee. That's not a want."
Beattie, who is also director of the Eastern Michigan University, Ypsilanti, Master of Science in Orthotics and Prosthetics program, says sometimes a want is simply not realistic for the patient given his or her unique health history, and that conversation can be tricky.
"A patient may see a story on 60 Minutes with an amputee running around a track and comes in and says, 'Why can't I run?' And you think to yourself, 'Well, let's see, you're 75 years old, you're 50 pounds overweight, you have diabetes and heart issues. Is running in your best interest?' It's a bit of a balancing act. I try to always be truthful with patients. I always listen to them, but sometimes my job is to be the bearer of bad news."
Montgomery adds that in addition to physical health, she considers emotional and psychological health. A patient with depression or alcoholism, for example, may not have the motivation to learn how to use a high-tech device or to use it to its fullest capability. In this situation, suggesting another device that is adequate rather than a more sophisticated device may be the ethical thing to do.
Pros and Cons
Both Carroll and Beattie say that a discussion about the pros and cons of the patient's chosen device often illuminates disadvantages of the device that the patient may not be willing to accommodate. Does the device solve a problem the patient doesn't have? Does it add too much weight? How will it look?
"Everything comes with a cost, and the cost is not always monetary," Beattie says. "For example, you could put a rotator on a prosthesis that will allow the patient to cross legs when they sit down. It's a wonderful widget for changing your shoes... but it takes up space in the prosthesis, and it would be a question of whether the patient would be willing to compromise the cosmesis of the prosthesis-the knees being misaligned-for that convenience. So that would be the sort of thing the patient would have to weigh for themselves."
Carroll says he likes to paint an image in the patient's mind about wearing the device. This exercise helps the patient understand the dynamics and weight of the device. If possible, he lets the patient hold the device, but just looking at a diagram is often enough to provide the visual cues necessary to illustrate how the device would work in his or her situation. For example, if Carroll suspects the added weight may be difficult for the patient to accommodate, he'll let the patient hold something that weighs that extra three pounds.
Let's Try It
After explaining the pros and cons and reviewing goals, the patient may still be keen to try something new. Beattie says it's important to accommodate requests if they are reasonable and safe for the patient, even if you don't think the patient will get much benefit from the device.
"I'm not always right," she says. "I had a gentleman who was convinced he wanted a foot with more movement.... I told him I thought he would be better off with something more solid, but let's try it and see. I got him a foot that had a lot of movement.... He hated it. But that's one example. There are other examples where I'll try that foot on somebody and they'll love it. Sometimes they're right. There's no harm in trying things."
Montgomery has a similar viewpoint and says it can be difficult to explain biomechanics 101 to patients, and it's better to let them try their device of choice so they can understand what you're saying. "It's about trying to get to common ground," she says. "When there is a lot of respect both ways, you take the time to get to where everyone understands, and sometimes that requires extra time and money. Sometimes, I'll go down a path to prove a point and find that I disproved the point."
Townsend says he relies on trial programs offered by manufacturers to accommodate patient requests. He has also acquired two microprocessor knees with help from manufacturers. The advantage to having these units in-house, he says, is that there are no time limits for the patient to try them. Carroll counters, however, that trial programs from manufacturers are often too short for the patient to learn how to use the device adequately. Instead, Carroll says, clinicians should be confident in their expertise and be prepared to invest time in educating the patient.
Know Your Technology
Townsend adds that trying a device, even if it doesn't work out, has important educational benefits for the practitioner. With an industry exploding with sensors, microprocessors, and myoelectric systems, it can be a challenge for clinicians to know how all the components work and for what type of patient they are appropriate. Yet this knowledge is absolutely essential to serving the patient, Townsend says. "If the patient comes in stating that they want to try this new technology and the prosthetist isn't familiar with the technology," he says, "then [the prosthetist] might steer them in a different direction, and I think that's not necessarily the best way to go."
Additionally, Muller says, it's important for practitioners to know enough about a product so they don't mislead a patient about its capabilities. The value of technological knowledge has prompted CSUDH to add a course to its O&P master's degree program. The new course, "Applied Technologies in O&P," covers biomechatronics, 3D printing, custom silicon technologies, dynamic sockets, sensors, and other new technologies.
"We had to go a step further in teaching our clinical students about the technology so they can answer the questions for the patients," he says. "It's also important for them to be able to talk to the designers of those components and convey what their patients want from them-to have the same kind of language."
Assessment Tools Provide Clarity
One advantage of allowing a patient to try a product, Townsend says, is that not only do you let the patient actively participate in the decisionmaking process, but you can also accumulate data to document improved functional outcome and justify the purchase with insurance.
Muller says documentation is crucial, and an assessment tool can provide clarity over emotion. "There are so many choices out there," he says. "You can make a $5,000 prosthesis, or you can make a $150,000 prosthesis. And we can't decide [which is best] with subjective information. We have to do it with an objective outcome to prove it."
With assessment tools now becoming more commonly used and built into practice management programs such as OPIE Software, Muller says, documented outcomes will become routine and will always be the surest method for showing the patient, and third-party payers, the suitability of a specific device.
Occasionally, after adequate discussion, the practitioner and patient still don't agree on the most appropriate product. In this situation, Beattie and Montgomery say they give the patient intermediate goals to prove that he or she is capable of using the desired device to its optimal performance. Montgomery offers this example: "I have a guy that I think has the ability to be in a microprocessor knee, but he looks horrible on paper.... He's been in a wheelchair now for over a year. If I put him in a microprocessor knee, that's a decision that could be heavily scrutinized. What if he just sits around and watches TV, and doesn't do all the things I thought he would do? Instead, I could fit him with a basic lowtech option and let him prove himself. I could document that he's doing everything I thought he would do. Then I could get him the microprocessor knee."
With the future of O&P becoming even more high-tech, it's certain that a practitioner's ability to deftly manage patient expectations will continue to play an important role. As practitioners, it's great to offer options for improved mobility and watch patients do things they couldn't do before. But Montgomery says that somewhere in the glamor of high-tech devices is the person using it. You can't rule out the human factor, she says. Technology can only take you so far.
"I've had amputees look at someone who is running and say, 'Well, they must have a good leg, or a good prosthetist, or a good residual limb,'" she says, adding that a lot of that drive comes from personal motivation. "I had a patient tell me once that he was climbing a 14er [a 14,000-foot-high mountain]. Somebody passed him on the trail, and they said, 'Wow, it's amazing what technology can do now.' He was really offended because this was pure determination, and will, and hard work. Of course, it helps to have a good prosthesis, but the bottom line is that this is not technology doing this. He would say, 'This is me doing this.'"
Linda M. Hellow is a freelance writer in Centennial, Colorado