Disagree or accept?

Dear blog readers,

I would like to hear your advice for a dilemma that occurred to me at work. This happened on the stroke unit where acute stoke patients are treated after stroke until they can go to a rehab clinic or home (about 3-5 days usually I would say).

I was assessing an about 60 year old patient that was suffering from a stroke in the brain stem for dysphagia. He was diagnosed with a Wallenberg syndrome. He clearly showed difficulty swallowing but it was impossible for me to tell if he was able to swallow at all or if he was aspirating every time (going into the lungs instead of stomach). So during our daily rapport I recommended to do a videofluroscopy to have a look at what I can’t see from outside. The assistant doctor agreed and I explained him which steps he had to take. The day after he told me that the senior physician refuses to do the examination with justification that most patients with dysphagia are better after two weeks anyway (which he told the patient) so it would not be worth it. I did not agree with this. Generally stroke patients with initial dysphagia may recover quickly. In patients with Wallenberg syndrome some may see decrease in their symptoms within weeks or months and others may be left with significant disabilities for years. Of course there is still a chance (even it is a small one) that this particular patient will recover that quickly. If I don’t know in more detail what happens during swallowing my therapy is much less specific and probably not at the right intensity because I have to be careful not to provoke pneumonia.

So I have the choice between disagreeing with the senior physician. This means I question his prognosis and he might feel like I overstep my competence which can lead to less good atmosphere in the team. At the daily meetings only the assistant doctor is present which is under pressure from both us therapists on the one side and the senior physician on the other side.

Also if then the senior physician would agree it may question his credibility from the patients point of view and make him insecure.

If I accept the decision it affects the patient and the quality of the therapy he receives. He might be nourished unnecessarily much or long by nasogastric tube which is uncomfortable and often leads to diarrhoea. Also the taste in the mouth is very unpleasant and it’s psychic very hard not to eat for a completely conscious patient that has to just lay in bed for most of the time (at the start anyway). What would you do?

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2 Replies to “Disagree or accept?”

  1. It seems you’re talking about different levels of power in the team, which also has implications for establishing trust and credibility with the patient, as well as other team members. You’re right in the sense that you don’t want to disrupt the dynamics of the team, which may have negative long-term effects, but you also want to make sure that you’re doing the best thing for the patient.

    In South Africa, because physiotherapists are first line practitioners, we would be able to order the test that we think is necessary, and not be questioned on it. In other words, we do not have to ask for permission to manage the patient. We would only need a good reason for wanting to order the test in the first place, but no-one could say that we can’t do it.

    It’s difficult to give advice because we don’t all know the context of your team dynamics. Is this something that can still be discussed, or is this the end of the story? How open is the physician to continued debate on the issue, or is their word final? You may need further evidence to support your reasoning but in many cases this may simply be taken as a confrontation by the physician because you’re “proving” that they’re “wrong”. I have no easy suggestions, other than to keep trying to make sure that your patient’s needs are the driving motivation behind your decision. If you’re always in the best interest of the patient, who is vulnerable and often has very little power in these situations, it would be hard to say that you’re doing the wrong thing.

    I would very much like to hear if anyone has any other ideas in this situation?

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  2. Hi there,

    Physiotherapy is a patient-centered approach therefore our main focus and goal is to improve the patient’s quality of life. You not only want to treat the patient’s current problem but you also want to prevent secondary complications such as pneumonia and possible lobe atelectasis with regards to this patient. Therefore you have the patient’s best interest at heart.

    In my previous placement I was also exposed to acute strokes. I found during my experience there that aspiration happens extremely easily. Incorrect handling of patient, incorrect turning and incorrect positioning can all lead to aspiration. I had a patient who I needed to suction because he had a very weak cough. I could hear audible grunting before auscultation and decreased air entry basally in the one lung. When I suctioned the patient I suctioned up liquid that resembled the feed that the patient was receiving. The patient was aspirating.

    I recorded my findings in the Doctors notes and I asked them to reassess the patient. The doctors ignored my request and eventually the patient developed pneumonia. From my side, I did everything that I could’ve done, I requested tests and I wrote my findings daily in the Doctors notes and the Physiotherapy progress notes.

    I find every clinical setting is different, I’ve had doctors follow up on my documentation and provide me on feedback.

    I think as students, although we are in our final year several members of the multidisciplinary team still view us as “students who are still learning” and don’t always take our opinion into consideration however it varies from placement to placement.

    If you look at things realistically, we as students don’t have a lot of power therefore we are often ignored. I think in your case, if you have reasons for why you think that the patient should have tests done to see if they are aspirating and if you document everything in your notes and the doctors notes then you’ve done what you can. I also think in the clinical setting if you get the physiotherapist to approach the physician then the doctors might take your suggestion seriously.

    Its a tough situation because you don’t want to cause tension with the team dynamics but you are there to help the patient. The physician could gain a great amount of respect for you if you are right and if you are wrong, its clarification that the patient isn’t aspirating and its a learning experience for you. Its better to be safe than sorry, you would rather want to double-check that the patient isn’t aspirating than have your patient increased their hospital stay and delay their rehabilitation due to pneumonia or lobe atelectasis.

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