Analysis of patient-physiotherapist interaction in an orthopaedic outpatient setting

Research in health care communication has gained importance in recent years. Reasons are found in increasing patient autonomy and expectations regarding quality of care. Professional practice guidelines prescribe health care professionals in general and physiotherapists in particular to include patients into the decision-making process and to establish collaboration in order to elaborate therapeutic goals and treatment plans. Clinical decision-making is defined in the literature as either an intellectual process of clinicians seeking to arrive at a diagnosis or management plan for patients, or as a phenomenon that requires social and linguistic skills. Social skills have been recognised by researchers investigating clinical reasoning strategies. Decision-making including patients' preferences is promoted as there is evidence that it improves clinical outcome. Evidence on goal setting shows some benefits perceived by patients and professionals regarding involvement in care. Most of the studies, however, are based on personal accounts rather than on observations during consultations. Some evidence of patient involvement in goal setting exist in neurologic physiotherapy which contradicts some of the basic assumptions of patient participation. Nothing is known in the context of orthopaedic outpatient physiotherapy. In summary, there is a need to know more about the way the interaction between patients and professionals takes place. The interactive nature of physiotherapy (using verbal and non-verbal communication) has not yet been fully described. This study will offer some insight into the clinical decision-making process in general, and in goal-setting and treatment planning in particular.Objective: The aim of this research is to shed light on patient-physiotherapist interaction during initial encounters in musculo-skeletal physiotherapy, and in particular on the goal-setting process and how decisions are made concerning the choice of treatment modalities. Method: Three different physiotherapy practice settings participate in the study: an outpatient clinic based in a public hospital, a private practice in in the outskirt of a city and a private practice in a small village. 60 consenting outpatients seeking physiotherapy for their musculo-skeletal problem and their therapists will be videotaped during five consecutive sessions. Conversation analysis (CA) is chosen as a method to help describe actual interaction. CA has its intellectual framework from ethnomethodology and provides an understanding of how sequences of interaction shape the encounter in an institutional setting. Its underlying assumptions are that talk (or any social action) is context shaped, context-renewing and that there is a mutual understanding between participants through sequential architecture of intersubjectivity. The video data (150 hours) will be watched, and sequences related to goal setting and treatment planning will be selected. The analysis will focus on how turns are design, what vocabulary is used, what type of corrections (verbal or in action) are used and how sequences of talk or movement are organised. Conclusion: A better comprehension of the interaction between physiotherapists and patients could help reconsider, confirm or refute some of the policies advocated in physiotherapy regarding patient participation in physiotherapy. A deeper understanding of how patients and physiotherapists communicate in an outpatient physiotherapy practice could lead to sensitising professionals on their communication skills.

• FNS - Fonds National Suisse - DORE