The right to be a patient. (Editor's Note).

Barriers take many forms. Often the most impenetrable barriers have little physical substance. In one of this month's articles, we see the building blocks of a barrier, one that might be stronger than we had imagined.

In the abstract of their article on work-related musculoskeletal disorders (WMSD) among physical therapists, Cromie and colleagues begin with the following contention:

Knowledge, skills, relationships, and attitudes of caring and working hard are all thought to be valued by physical therapists.

The article examines how these values lead toward the development of work-related musculoskeletal disorders among physical therapists. Perhaps more importantly, readers also gain some insight into how physical therapists behave once these disorders, develop.

Cromie and colleagues suggest that physical therapists differ from patients in some ways, but there is a troubling indication that physical therapists seem to believe they are different from their patients in many ways. According to the data provided in this qualitative study, physical therapists often allow themselves to behave in ways that we would view as counterproductive in patients. In other words, there is us, and there is them!

According to the physical therapists interviewed, we should, for example, be almost immune from injury because of our knowledge; however, as Cromie and colleagues note, "Not only does this belief in a right way as a preventive strategy give therapists a false sense of security, it has moralistic overtones that assign blame.... "

Or, as one of their subjects said, "When I hurt my low back, walking that guy, I felt I'd done it wrong, but I couldn't for the life of me work out why. But I still had the injury, so I knew it was my fault."

Another subject was more blunt: She characterized getting an injury as a personal failure.

Although the paper we publish this month explores injuries among physical therapists, it also offers a window into a problem of greater dimensions and consequences. For almost 3 decades, I have been amazed by the frequent inability of members of what we call the "helping professions" to seek help. An overwhelming number of health care professionals seem to need to differentiate themselves from their patients and clients. Despite what might be the humanistic orientation of these professionals, they seem to have a need to feel superior and apart. The wall we build between our patients and ourselves appears impenetrable, in part because we do not even acknowledge that it exists. Others can ask for help. Not us.

Cromie et al begin to make visible a part of this wall that we have created and, at the same time, they provide a lot of other insights into the injuries that physical therapists sustain on the job. The wall is something that should bother us. Given our behaviors, its existence should not surprise us. In addition to informing us about WMSDs, perhaps the work of Cromie at al can lead us to reflect on how we function--and how we should function.

Why do we behave the way we do? The answer is complex, and studies such as the one we publish this month are a step in the right direction; however, the focus is on what exists now, not on how it came to exist. We can think of many reasons why physical therapists might behave as though they are different from their patients. There is no better example of the inherent arrogance and the setting apart of health care workers from their patients and clients than the SOAP (Subjective, Objective, Assessment, and Plan) note. In SOAP notes, we characterize what patients say as subjective, regardless of whether it has a physical reality or a replicable element. In other words, we begin by devaluing what the patient says.

Although the dictionary may define "subjective" as something unique to the individual, * we consider anything that the patient says to be subjective, to the point that we would consider the patient's report of an amputation to be subjective--even as we stare at the residual limb! Here alone should be a hint that we have created a mighty wall.

Ironically, of course, much of the most useful information about a patient's condition comes from the patient interview (a term that could easily replace the silly category of "subjective").

What we consider to be objective ([dagger]) also borders on the comical. Anything we say or see and any of the measurements we obtain, we consider to be objective--even though the word "objective" means "not influenced by personal feelings." In writing SOAP notes, we do not care whether the physical therapist influences the quality of the information because we include in the objective category anything that the therapist sees or says. We do this even for measurements that are known to be highly unreliable and, therefore, greatly influenced by the people who are taking them! We give undeserved value to that information, which can only hurt our ability to provide patient care. Wouldn't it be just as easy to call the phase of data collection the "examination" rather than the "objective phase"?

As if the SOAP note did not do enough to overvalue what we say and to devalue what the patient says, there are people who have influenced the profession to use these aberrations of language for their own advantage. For instance, why bother studying reliability when some schools of manual therapy already call their examination procedures "objective"? Why value the patients' descriptions, which may or may not fit with our clinical impressions, when we can devalue them by calling them "subjective"?

The SOAP note is not the problem--but it is more than a symptom. Perhaps we can think of it as a comorbidity that contributes to the condition. This condition has some interesting side effects. When health care workers set themselves up as superior to their patients, it has been argued, they deprive patients of full participation as decision makers. The work of Cromie et al suggests that, when we maintain a barrier that blocks the shared humanity of patients and professionals, we also deprive the health care worker of the right to be a patient.

Jules M Rothstein, PT, PhD, FAPTA
Editor in Chief

* "Subjective" is defined by the Random House Dictionary of the English Language as "existing in the mind; emphasis on one's own moods, attitudes, opinions, etc." (1)

([dagger]) "Objective" is defined by the Random House Dictionary of the English Language as "not influenced by personal feelings, interpretations, or prejudice; based on facts; unbiased; intent upon or dealing with things external to the mind." (1)

References

(1) Random House Dictionary of the English Language. 2nd ed. New York, NY: Random House Inc; 1987.