According to Stern (2006), health professionals should consistently demonstrate core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication and accountability, and by working together with other professionals to achieve optimal health and wellness in individuals and communities. This year I have become more intentional about matching the description of professionalism. When thinking about where I stand with professionalism, one of the weaknesses I identified is the poor long term planning of my patients. This weakness became evident in my second block, an assessment block. At the end of my exam, the examiner asked me what my long term plan was and instantly I was thrown off. Because it was an assessment block, I had to think quickly as I did not have the extra time as I would have had on a treatment block. When I answered, I only spoke of the physiotherapy goals I had in mind and later my examiner brought it to my attention that referrals to other disciplines are part of long term planning. According to the Health and Care Professions council (2013) a physiotherapist must know the limits of their practice and when to refer to other disciplines. The Health and Care Professions council (2013), outline requirements of good professional practice of physiotherapists; thus according to this source, being able to refer your patient appropriately is part of embodying professionalism. My first ethics blog post focused the topic of professionalism and comparing my professionalism to the standard that literature describes. As my weaknesses and shortcomings were identified in this post naturally, long term planning came up. I received a comment on my blog post that suggested that I research the International Classification of Functioning, Disability and Health (ICF) to guide my thinking when regarding long term planning of a patient, thus addressing this weakness.
Link to that blogpost: https://iepcourse.wordpress.com/2016/08/05/be-careful-the-tables-might-turn/
According to WHO (2001), the ICF is a framework for organizing and documenting information on functioning and disability. It conceptualizes functioning as a ‘dynamic interaction between a person’s health condition, environmental factors and personal factors’(WHO, 2001). By the definition alone, it can be inferred that the ICF promotes a holistic approach to treatment. In order address my poor long term goals, I incorporated the ICF into sessions with my patients. After the gaining information from the folder and conducting the subjective interview, I roughly drew up an ICF. This helped me to refer the patient according to the impairments identified in the ICF, for example if social issues were identified in environmental factors the patient was referred to social worker. Not only did the ICF help with patient referrals, but I was also able to categorize impairments into problems that could be addressed in the short term and contrastingly, those that could be addressed in the long term. If I had not blogged about this weakness, I would not have received the comment to research the ICF, thus, this weakness may not have even been addressed.
Integrity and wrongdoing
For a large part of my clinical career as a student, my SOAP notes were not always detailed, especially when it came to outlining the plan for the next session. Usually my time was spent in the other sections of documentation and then I ended off each note with “continue RX”. According to the HPCSA (2008), one of the main responsibilities of a health professional is to keep accurate patient records. The HPCSA (2008) goes on to say that accurate documentation is needed for the ongoing management of the patient and to promote good clinical practices. This year, a clinical portfolio was introduced to the clinical module to replace the clinical file that was required in previous years. Many changes resulted as a result of this introduction, and one of the changes was the marking of student’s SOAP notes by the supervisors. This served as an external source of motivation for me to be more detailed and extensive with my documentation. However, I found that this external source of motivation was short-lived, as occasionally I would still just scribble “continue RX” at the end of my notes or fail to include detail in the documentation when I was in a hurry.
In my last block, I had the opportunity to work with a physiotherapy student from a different university. One day, the topic of documentation came up in conversation. The student was complaining about how qualified clinicians tend to scribble the bare minimum and then we as students are left to re-assess the patient due to the lack of detail. While we were talking, she stated, “ Poor documentation is not fair to our patients and actually, I’d say it falls in line with poor integrity and wrongdoing as a clinician.”
Her statement made a huge impact on how I viewed documentation. I realized that I should document correctly, not only to get good marks or to allow the next physiotherapist to continue my treatment with ease, but that it was the patient’s right. Abdelrahman and Abdelmageed (2014) state that the maintenance of good medical records ensure that a patient’s assessed needs are met comprehensively. As a healthcare worker, it is absolutely essential to meet the patient’s needs. The HPSCA (2008) states that it is health care practitioner’s responsibility to make the care of their patient’s health care their first concern. As a result of the conversation with the physiotherapy student and additional research done to understand the importance of good, thorough documentation, I sought a way to improve this. In an attempt to improve my documentation, I did research on how to properly write physiotherapy SOAP notes. I found that I knew the components of what was required, but I was made aware of common errors. According to Quinn and Gordon (2003), common SOAP note errors include passing judgment on a patient (subjective), a lack of detail, a global summary of problems, vague assessments and failure to indicate upcoming plans correctly. I wrote the errors in a book that I carry around at clinical blocks and I would often refer back to the book after writing my SOAP notes to ensure that I was not missing anything. Additionally, Abdelrahman and Abdelmageed (2014) outline principles of good documentation which includes: writing legibly, including details of the patient, date and time, avoiding abbreviations, not to alter an entry or disguise an addition and lastly, to avoid unnecessary comments. After learning this, I incorporated these principles into my documentation. Having the list of common errors and knowing the principles of good documentation definitely played a role in improving my ability to correctly document.
Consideration of patient’s rights
During my last block, a medical student approached me and asked me to assist him with acquiring blood cultures from one of my patients. The patient was known to be difficult as she was not very compliant and often resisted treatment; the medical student wanted me to hold the patient down while he got the bloods. Throughout the encounter, I was outraged by the student’s patient approach and I found myself silently criticizing his work ethic. He did not clearly state what he was doing or the purpose thereof, he simply stated that he needed to get blood from her. The patient was distraught and started screaming and tearing up, probably because she had no idea why he had to do what he was doing.
After some thought I decided that rather than being judgmental of the medical student’s actions, I was actually gaining an outside view of what my patients might feel when I approach them for treatment. I realized that I sometimes I, too, was guilty of not always clearly explaining my purpose, my intentions, the benefit for the patient and what treatment entails. I became more aware of my approach after this encounter, and I caught myself giving patients watered down explanations in the simplest of terms (which may undermine the patient’s intelligence). Often times I would say something along the lines of “I’m going to give you exercises to make you better”, which is very vague. According to the HPCSA (2008), patients have the right to obtain information from the practitioner about their treatment options, the complexity thereof, the risks involved, the adverse effects of treatment and the nature of treatment. It is important to speak to your patient’s in layman’s terms, however patients still deserve to receive a thorough explanation so that they can clearly understand what is being medically done. The HPCSA (2008) states that health practitioners are responsible for providing information to their patients in a way that they can best understand in a manner that takes into account the patient’s level of literacy, understanding, values and belief systems.
Again, I was able to learn from the student physiotherapist from the other university. I saw that whenever she explained things to her patients, it was done with careful thought and in simple terms, but never undermining the patient’s intelligence while doing so. Moxey, O’Connell, McGettigan and Henry (2003) state that the manner of presenting treatment alternatives and outcomes may influence patients’ decisions. In the YouTube video linked below, physiotherapist Lorimer Moseley explains how he explains pain to patients. Although he specifies on how to explain pain, his approach may be used in all clinical scenarios where an explanation is needed. Moseley (2013) states that his strategy is to (1) engage the patient with stories or scenarios and (2) to establish a trustworthy relationship with the patient. After learning this strategy, I started to incorporate it into my approach. I started to explain treatment specifically for the patient and make it personal to their situation, instead of providing a generic and vague explanation. By making it more personal and engaging the patient I was also developing a relationship with my patients. The more I practiced this strategy, the more I could see a difference in my patients. The patients showed a better understanding and more enthusiasm to treatment.
This year through the ethics module, I was made aware of several flaws in my professionalism and ethical practices. The ethics course involved blogging. This required me to reflect on different clinical scenarios from different blocks, and in doing so I was able to identify challenges and weaknesses. The course also required consultation of references which aided in correcting and improving my faults with literature to help to guide the change. Some of the challenges that I have improved on are: long-term planning of my patients which aligns with professionalism, ensuring accurate and detailed documentation and thoroughly explaining treatment to patients. In my opinion, I have grown and developed in the area of professionalism and ethics.
Abdelrahman, W. & Abdelmageed, A. (2014). Medical record keeping: clarity, accuracy, and timeliness are essential. Retrieved from http://careers.bmj.com/careers/advice/Medical_record_keeping%3A_clarity,_accuracy,_and_timeliness_are_essential
Health and Care Professions council (2013) Standards of Profiency-Physiotherapists (1st ed.). London. Retrieved from http://www.hpc-uk.org/assets/documents/10000dbcstandards_of_proficiency_physiotherapists.pdf
Health Professions Council of South Africa. (2008). Booklet 14: Guidelines on the keeping of patient records. Retrieved November 4, 2016 from http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_14_keeping_of_patience_records.pdf
Health Professions Council of South Africa. (2008). Booklet 1: General Ethical Guidelines for the Health Care Professions. Retrieved November 4, 2016 from http://www.hpcsa.co.za/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_1_guidelines_good_prac.pdf
Moseley, L. (2013). Lorimer Moseley Pain DVD How to Explain Pain to Patients. Retrieved from https://www.youtube.com/watch?v=jIsF8CXouk8
Moxey, A., O’Connell, D., McGettigan, P., & Henry, D. (2003). Describing treatment effects to patients. Journal Of General Internal Medicine, 18(11), 948-959. http://dx.doi.org/10.1046/j.1525-1497.2003.20928.x
Quinn, L. & Gordon, J. (2003). Functional outcomes – Documentation for rehabilitation. Saunders (Elsevier Science), St. Louis, Missouri.
Stern, D.T.(2006). Measuring Medical Professionalism. Oxford University Press. New York, NY.
World Health Organization. (2013). How to use the ICF: A practical manual for using the International Classification of Functioning, Disability and Health (ICF). Exposure draft for comment.Geneva: WHO