The O&P Patient’s Orbit: Applying Contextual Knowledge and Systems-based Care

ONE of the unwritten rules of O&P pediatric care is, “If you fit the child, you fit the parents first.” Obviously, this refers to the thought that the child is part of a greater social system that includes the parents and other caregivers who provide support not only for the wearing of the device, but emotional support. This means addressing the parents’ and caregivers’ anxiety in addition to or even to a greater extent than the patient. The evolving and dynamic nature of pediatric patients means that the fitting priorities, expectations, and functional goals are continually shifting. The parents’ involvement means that constant communication and personal trust must exist between the O&P clinician, parents, and child. Difficulties can arise in the social system from misunderstandings of the expectations and limitations of the technologies or processes. This occurs because pediatric patients may not be able to understand those goals or express their own opinions about them. Developmentally, they are still learning basic human functions of communication, social interaction, mobility, and hygiene. The responsibility falls to parents or guardians who must instruct and challenge patients on a daily basis. Conversely, parents may also be dealing with the perception and anxiety of limb difference within their social culture so they may make choices based on their extrinsic biases. It is essential that practitioners attempt to engage these contextual social challenges before they arise and develop an overall strategy with buy-in from the parents. This provides the parents with an opportunity to take part in decision-making to discern future changes, rather than making a series of tactical and stressful decisions. This is not to say tactical changes in the plan do not happen, but rather the relationship can react appropriately. In this way, clinicians learn that constant and empathetic communication is the most effective and critical tool for pediatric management. Brian Giavedoni, MBA, CP/L, manager of O&P, Children’s Healthcare of Atlanta, acknowledges the necessity of constant communication. “Yes, this is still a principle that is followed and…may differentiate clinicians who are successful at fitting pediatric cases and those who are not. He adds, “We should reflect about our perspectives as providers. For example, if we ask about pain when none was reported, are we introducing a concept that was previously unknown? We can inadvertently become part of the system and introduce a measure of bias if we aren’t careful.” Social Context Matters In this way, we can apply the same contextual knowledge to the treatment of adults. Clinicians can recount numerous experiences of O&P wear being encouraged or discouraged by the patient’s interaction with a family member. I remember a prosthetic arm user who had been very dedicated to using his arm who discontinued wearing it. When I asked about it, he said the arm fell off the center console of his car and slid onto his wife’s lap and she said, “Ewwww.” She paused and said that it had just surprised her, and she was not disgusted in any way. But that one misinterpreted interaction caused a discontinuance of wear. When asked about social systems, Brad Veatch, owner, ToughWare Prosthetics, Colorado, agrees. “I value social systems in our treatment process, but we forget the power of the family. I have two powerful stories that still live with me. We were in Jamaica providing care, and we learned of a young man of 18 who…suffered a traumatic amputation. He was very depressed and had muscle problems. When we were in town, he was not enthusiastic about a prosthesis. But his mother wanted him to be fit with a prosthesis and practically dragged him by his ear to at least try an arm prosthesis. When his nephew with his group of friends saw the arm, they were so excited for him, and called him the Terminator. Because of that, something clicked with him psychologically and he wanted to wear the arm. “We were back providing aid in Haiti in 2012 after the big earthquake that was there, and we had several patients. One of the amputee peer support people showed up with a number of giveaway Frisbees, and we kind of made fun of him for it. But we made a small contest: If patients could catch the Frisbee, they would win the Frisbee. It was amazing, because they would go through 15-20 minutes of training for that colorful little plastic disc,” Veatch says. This is why it is valuable for clinicians to gather a patient’s social group, those who interact with the patient, for adults or children. During evaluation and follow-up appointments, the players in the social group can be used to validate (or disprove) the information the patient is providing and function as coaches. When I asked the husband and wife in the previous example if he did any heavy lifting, he passed it off as only light activity. His wife stared at him intently and said, “That man is lying to you! He is gardening morning, noon, and night—digging, weeding, turning compost, building walls, pouring concrete.” Family members can also deliver small coaching opportunities. One transfemoral prosthesis user was exhibiting the common gait deviations of lateral trunk bending and circumduction. His wife asked me why he walked the way he did. I explained that it was because his previous prosthesis felt uncomfortable, and his knee was aligned with too much stability. I showed them how to correct it, but I was satisfied with his gait since the deviations were minor and typically challenging to eliminate. At the next appointment, his wife was giving him consistent and detailed gait instruction. She had become an expert observer, and more importantly he was listening to her. Nested Social Structures and Contextual Awareness Each of us exists in a nested social system, a hierarchal arrangement of social systems in which component groups are interrelated and ordered. The individual may be connected to a small number of very intimate relationships (such as parents or spouses), which are then related to the healthcare group and extended family, who are in turn related to an even greater community. The key is that the social system supports or discourages certain behaviors. It establishes a set of norms, behaviors, or informal rules the group follows. 1 Any time something new is introduced to the system, such as a prosthesis or orthosis, the group can either act to adopt the change or reject it. Knowing this, contextually aware clinicians can look to the social group to determine the challenges and expectations and not only address the direct acceptance with patients but also reinforce the indirect relationships of the social system. This requires increased attentiveness to the context and system surrounding each patient that is truly individualized and unique. When applied to human factors, contextual awareness looks at habits, emotional states, social environments, and desired tasks. Communication in relationship building is essential to understanding contextual awareness. “I had a patient who just came in today, and we talked about her 85-year-old mother’s remarriage and her one-year anniversary. We talk about her kids, and all her family and friends. I feel we share that relationship built on trust. I don’t learn about the patient’s context to reinforce practitioner trust for transactional reasons. It is because I have an authentic and genuine interest in them,” says Mike Pack, CP, regional clinical manager of Ottobock-ALS, Arizona. “Because they know I care, they are trusting of my clinical direction for them and more willing to try new things and innovations. I tell younger clinicians the relationship you build enables you to make mistakes that will inevitably happen and provide you some tolerance during the fitting process. “Joe Leal, my mentor, told me something: As long as the patient knows you love them, they will give you a greater amount of consideration and cut you some slack during the challenging times. Of course there is a limit, but they know you are invested in the long haul, so it really establishes trust, which is essential to successful outcomes.” Pack adds that he receives personal benefit as well. “Not to be selfish, but it makes my day go much better too. I feel I have familial bonds with many of my patients, and I get a better take on success and a sense of pride there. It is important to not just focus on the task at hand in providing just a device. Our value is really the quality of life we are contributing to. I feel if you become a friend, it trickles down, and you not only grow your business, but you become someone they genuinely want to share their experiences and accomplishments with.” Systems Thinking in Healthcare The concept of understanding this bigger picture and finding root causes is also referred to as systems thinking. Rather than focusing on a single person, it reveals the direct and indirect effects that each person has on each other in the system. The understanding of human relationships in a systematic, thoughtful manner is critical not only to leadership in clinical groups, but generally in family and social groups as well. Murray Bowen, MD, a psychiatrist at the Menninger Clinic in Kansas in the 1950s described the relationship between mothers and their children with schizophrenia. Frustrated by the lack of progress when working directly with the children, he noticed that when he treated the mother’s anxiety, the child’s condition improved. 2 He believed that by treating the mother he could address the tension within the system, the mother-child couplet. 2 Later Bowen found that he could apply the same systems approach to families with other issues by first addressing the degree of anxiety or tension within the group. Bowen found that by treating the less reactive and more thoughtful person, the anxiety of the system was lessened. 2 It may seem counterintuitive to lower the anxiety of the less affected person, but what this does is to lower the system anxiety as a whole by treating the person who has the greater capacity to regulate their anxiety. Emotional Regulation and Personal Bias Some people are better able to understand how their actions contribute to positive or negative aspects within their social group. Others react to perceived threats and other’s actions before stopping to think, which can cause anxiety in the group with negative effects on communication and when adapting to new situations. “Emotional regulation is tapping into what the other person is thinking. It is critical that I do this to set a clear expectation. I must have an individualized level of deep empathy to understand the situation. Knowing what they are going through regulates how I do something with them,” says Karl Lindborg, CPO, LP , owner and CEO, Intersect Consulting. “One of the things I think about is how groups assess success. I need to know if anything has changed for organizations to affect their perception of success. How do you know what to provide a patient without knowing the reimbursement context? You end up unknowingly providing something they may have wanted, but it doesn’t fit the overall situation. I do conduct a critical review of my own performance to reflect on my motivations and understanding. Even with my successes I ask, ‘Did I have false expectations? Did I understand what was needed? What influenced me?’” Reflexivity is the process of self-reference by examining our own motivation and biases. It is a level of self-critique that recognizes our social system’s positive and negative influences on us by checking the accuracy of our own norms and perhaps readjusting them. Monks called this “examination of conscience” where we put our own motivations to the test. 3 What helps true innovators is to compare their logic to that of others and adjust it internally. This critical thinking is essential for improvement because it establishes an external measure of success. 4 Perhaps more experienced clinicians can keep success and challenges in greater perspective with their increased experience and long-term perspective. Students Need a Learning Context Students also exhibit this contextual systems awareness during learning. In my survey from 2012, Learning Self-Efficacy and Competency, 121 O&P students who had some patient interaction during their training rated their own abilities slightly lower as they approached residency. 5 Their experience allowed them to evaluate themselves extrinsically. In a sense, they knew what they didn’t know. In many ways, learning is done among peers in the student’s social system rather than from the teacher. This context-based social learning process, first described by Piaget and Vygotsky, lowered anxiety and provided an inherent level of challenge to improve. 6 Piaget and Vygotsky believed that people create learning contexts and learn from each other through the sharing and social interaction with individual experiences and ideas. By working together, they create a shared context and meaning that helps the individual learning become immersed in the learning culture necessary for organizational performance and innovation. 6 Clinicians Belong to Systems This concept of alleviating anxiety and providing scaffolding for new or innovative behavior applies to patients and clinicians. In a survey examining the differences between novices and specialist providers of upper-limb prostheses, I found that experts/specialists at institutions/corporate settings consult with 4.85 people outside of their group on average. Novices/intermediates only speak to 1.65. Speaking to more people outside of the immediate clinical group helps in two ways: The group can help lower the anxiety of trying something new and challenge the clinicians in their group to a higher level of innovative behavior and proficiency. 7 The social system of experts can also help mitigate self-bias by providing critique. In another retrospective survey of upper-limb prostheses, clinicians recalled their upper-limb fittings slightly less favorably when working with an experienced occupational therapist. Initially I struggled to understand this, but then I realized that the occupational therapist’s extrinsic review lowered the typical “halo bias,” or overly positive impression of oneself. The therapist was able to establish a higher level of expectations and proficiency for the patient. The practitioner remembered success as lower, but, as with the students, they were more aware of what they didn’t know and of the higher expectations. Developing Your Skill as a Systems Thinker Knowledge of systems thinking and contextual awareness helps us to be better clinicians by recognizing the social systems surrounding our patients. The challenge is looking beyond our direct interactions and understanding the context that surrounds the patient, family, clinicians, and healthcare companies and organizations. The concepts cause us to search for more information and data with a broader and multifaceted perspective to consider the indirect effects that require a deeper understanding. By creating a learning context, we can become better students, teachers, collaborators, and leaders. These extrinsic relationships can also temper our own halo bias and call us to conduct a critical review of our understanding beyond our immediate group. Our ability to seek this deeper meaning can differentiate us individually as well as the groups we serve. Gerald Stark, PhD, MSEM, CPO/L, FAAOP(D), is the director of clinical affairs for Ottobock Patient Care, Texas. References and Suggested Readings Northouse, P. 2010. Leadership. Thousand Oaks, California: SAGE Publications Inc. Bowen, M. 1978. Family therapy in clinical practice . Lanham, Maryland: Rowman & Littlefield Publishing Group. Jamieson, M. 2023. Reflexivity in quantitative research: A rationale and beginner’s guide. Social and Personality Psychology . 17:4. DOI: Pisapia, N. 2022. The examination of conscience: A preliminary study on the effects on metamemory after a 2-week practice. Frontiers in Psychology , Consciousness Research , Volume 13 - 2022 https://doi.org/10.3389/fpsyg.2022.838381. Stark, G. 2016. Development of an upper-limb instructional design to address self-efficacy among self-assessed novice and intermediate prosthetic clinicians. American Academy of Orthotists and Prosthetists Orlando, Florida, Schunk, D. (2012). Learning theories: An educational perspective (6th ed.). Boston: Allyn & Bacon. Stark, G. 2014. Upper-limb prosthetic competency and characteristics among self-assessed novices-intermediates & experts-specialists. ACPOC News 20(1). Riggo, R., and R. Reichard. 2008. The emotional and social intelligences of effective leadership. Journal of Managerial Psychology 23(2):169-85. Senge, P. 2007. Organizational Development. Open Future Limited. Retrieved from http://www.openfuture.co.nz/petersenge.htm. https://compass.onlinelibrary.wiley.com/doi/10.1111/spc3.12735#:~:text=Reflexivity%20is%20the%20act%20of,how%20this%20guides%20our%20work. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502599/ https://www.sciencedirect.com/science/article/pii/S0738399121004158

The O&P Patient’s Orbit: Applying Contextual Knowledge and Systems-based Care

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