Playing Beyond Nice in The Sandbox

One question that I routinely encounter from rehab professionals as I teach therapeutic neuroscience education across the country is this: “PNE is such great stuff!  But HOW do we get EVERYONE in our facility on board?”  That is the million-dollar question, isn’t it?  All too often we face frustration born out of our own facility or system’s silo-approach to patient care: we provide stellar education to our patients with complex chronic pain, have them on board and progressing towards meaningful life change, and then they go to that “consult” that was arranged six months ago.  They return to us, new plan in hand, because, lo and behold, it IS the disc/SI joint/labral tear/you-name-it that is the problem after all!  Inwardly, we scream, “Nooooooooo!!!”  Outwardly, we bite our tongue as we politely smile, re-group, and salvage the situation to the best of our ability.  It makes us wonder, is it even possible to create a culture within our systems that truly serves patients with chronic pain in an evidence-based, responsible, compassionate and effective manner?

Last fall, I had the privilege of getting to know several members of the Tomah, Wisconsin Veteran’s Administration’s rehabilitation team.  Hearing their story of implementing an innovative and highly successful multi-disciplinary pain program was one of the most exciting and encouraging experiences I have had in a long time.  After initially meeting at a CE course, the team was kind enough to invite an ISPI colleague and I to their facility to see first hand what they have been doing.  Watching the team in action gave us a glimpse of what is possible when a small group of committed individuals buckle down, cooperate, and keep patients at the center of their mission.

The PT-led team in Tomah brought about huge, in-house, multi-disciplinary change, and now their expanded, interdisciplinary team is taking steps to multiply that change in sister facilities.  Starting with their knowledge of pain science and the conviction that everyone involved in patient care needs to grasp how pain works, they did the hard work of initiating a culture change, from bottom to top and top to bottom. As I observed their interactions with one another, from the PT stationed right in Primary Care to offer early intervention alongside the physician, to the psychologist working alongside PT and OT for patients in the addiction program, to the chiropractor working on studying outcomes, to the pharmacists who shared their stratification of opioid risk procedure, I was struck by one resounding observation: humility.  The members of this team recognized their unique strengths and contributions to patient care, but also recognized the absolute need for their colleagues in different disciplines to treat the whole Veteran.  Under exemplary servant leadership, this team proved to me that it IS possible to change a culture within an organization, and it bolstered hope that a handful of committed individuals can, indeed, “change the world.”

As I reflected on what I saw in Tomah, as well as concepts of professionalism and moving above and beyond merely “playing nice in the sandbox,” I came up with a couple of Top 10 lists for in-house culture change.  While each system/facility has their own unique barriers to overcome, each discipline within an organization being guided by principles like the following can foster the kind of change we are hoping for.

 

Top 10 Things All Disciplines Can Do to Foster Culture Change

1) Remember: It’s. About. The Patient. (It’s always about the patient…check all egos at the door)

2) Get out of our silos and learn from one another (know our roles and the roles of others)

3) Language: speak the same language with emphasis on reassurance and hope:

  • Tissues heal!
  • The nervous system is plastic and change is possible!
  • Mantras: Sore but safe!

4) Leverage expectation (set each other up for success)

5) Perform skilled assessments (no business initiating “sensitive nervous system” conversations until we are confident that’s what is truly going on)

6) Build Trust/Therapeutic Alliance: Assure you have enough time to establish relationships to address the complexity of the pain experience (or refer to those who do)

7) Keep your own compassion /empathy fresh (personal life balance)

8) Provide positive environments (what’s on the TV in the waiting room? What’s on the covers of your waiting room magazines? Models/posters; Receptionists)

9) Have a pain champion: someone(s) in your discipline with the desire and ability to dive deep into pain science—learn from them! Consider in-house pain summits

10) Focus on function and celebrate success!

 

Top 10 Things we all need to STOP doing:

1) Using scary language

2) Sanctioning disability

3) Relying upon passive treatments, unless they are time-limited, supplemental and goal-oriented

4) Pushing patients before they are ready

5) Disregarding patients’ priorities/desires

6) Minimizing contributions of others

7) Hyper-medicalizing patients (too many visits)

8) Labeling patients by their diagnosis

9) Assuming patients can’t learn or that they want to be fixed passively

10) Assuming patients are faking

I’d be interested to hear your thoughts.  What has made your team soar?  What can we do to go beyond “playing nice” to actual bridge building?  How can we foster culture change?

 

 

10 responses to “Playing Beyond Nice in The Sandbox

  1. Belot Marj says:

    Thank you for this thoughtful and comprehensive commentary. I particularly like number 5 in th dos as I think this happens ALOT!!! judging from online health care professional discussions. Number 3 is also a good one in my mind. Passive modalities are not evil but should only be one small part of comprehensive care, especially in chronic conditions.

    1. Jessie Podolak says:

      Thanks for your comment, Belot. I have made the mistake in number 5 myself, in my excitement and enthusiasm re: PNE, jumping in sooner than I should when it comes to delivering the “good news” of neuroplasticity. It takes a bit of self-discipline to slow down and do a solid, comprehensive objective exam so that we can legitimately and responsibly deliver this hope-filled message. I appreciate your feedback!

      1. Bob Schroedter says:

        This echoes the first question in the Explain Pain Assessment: Does the learner even want to learn about pain?

        There’s always a need to learn more about pain from a lay perspective, but the patient has to want to go there in the first place. Nice post as always!

        1. Jessie Podolak says:

          Wise words, as always, Bob! :-) Everything that we know about behavior change points to the fact that people must WANT to change. There are many behaviors surrounding pain that may need to be modified. Assessing someone’s readiness and interest in hearing how pain works is the first step in matching the patient to the intervention. They have to want it!

          Take Care!!
          Jessie

  2. Paul Leverson says:

    Jessie…
    Thanks for sharing this victory!

    We practice in a system and culture which acknowledges only disability. Our objective forms measure it. We reimburse for it. We reward lifetime allowance for it. We know in brain science that what the brain focuses on, it reinforces it’s neuronet towards. What it believes to be true it accepts.

    Early on in the process, I honestly acknowledge to the pt. my own shortcoming…I am physically blind to disability…I only see A-bility.

    As we emphasize A-bility we see a spectrum of A-bility-ness. At any one time any person finds themselves at different places on this spectrum as the nervous system waxes and wanes in a rather broken world. Never DIS-ability…Rather, “less A-bility” or “more A-bility”. Our job is to help our clients improve their A-bility…to point them to a body in which they have been given a great and powerful gift of healing and getting better. Not to make allowance for their disability.

    Client by client, clinician by clinician, one by one, we build concensus. We build a haven based in the non-negotiability of absolute Truth, presented as gracefully as we can, to those who have never heard it. We become better, word by word, moment by moment, opportunity by opportunity, at communicating this truth in a way that is increasingly understandable and influential to those who hear it.

    It’s helpful to me to focus more on direction rather than position. This is especially beneficial to the pioneering mindset which, because of it’s nature, is usually out in front of what is popular or accepted (even before there is adequate “evidence” to support it!). Ironically, this is what we’re asking our pain science pt’s to do as well. Trust Truth…regardless of the immediate results (“I still hurt.”)…trust Truth.

    In the end, if we can get them to trust that Truth is actually True, neurologically, a change inevitably happens…GDNF/BDNF protiens are secreted differently…neuro-networks come alive while others are dampened. Sensors change.

    And…as a result…life changes.

    1 moment at a time…that’s how change happens. Focus on direction…not position.

    Peace.

    1. Jessie Podolak says:

      Always great to hear your thoughts, Paul! I echo your sentiments and appreciate your reminder that “client by client, clinician by clinician, one by one,” we get the privilege to make a difference. We are truly blessed to serve. Beautifully said.

  3. Tim Mondale says:

    Great post Jessie,

    How would this be for fostering culture change? Adding basic pain neuroscience into curriculum at the primary school level, and reinforce that with increasing complexity through secondary, and tertiary level education? I think this could potentially change society. Not sure what the push back would be though. I would hope it wouldn’t be we don’t have time to talk about that in school. What could be more important to society?

    Thanks again Jessie

    1. Jessie Podolak says:

      Tim,

      Thanks for your comments! I am 100% on board with that idea! We are advocating for that type of culture change with our middle school research: https://www.tandfonline.com/doi/full/10.1080/09593985.2017.1423142

      As far as push back, I can tell you that many of our local schools have welcomed PTs/OTs sharing this knowledge with middle school students. In speaking with government officials about this, however, there has been some question about the necessity/priority of it, as schools have SO MUCH to get in for curriculum, as well as other issues to deal with (student safety, bullying, etc.). Pain is a huge societal problem, and likely, very related to those very things that young people are anxious about today. Educators have so much work to do, so anything we can do to empower and equip them (as well as society at large: families, churches, community groups, etc.) will hopefully be of benefit! Be it grass-roots efforts, or sweeping curriculum change, we need to keep getting the word out!

      Thanks again for your thoughts!!!!

      Jessie

    2. Paul Leverson says:

      The educational system is the institutional lever for cultural change..
      Good…and Bad.

      It would be quite effective. But would have to be first accepted by those who manage the institution (government). That’s why I was so encouraged by this entry. The VA system is intimate with the government system. It would serve as a portal to allow penetration past the now seemingly impregnable shell of tradition, cronyism, corruption, etc.

      1. Jessie Podolak says:

        Paul,

        Here is another encouraging story of multi-disciplinary cooperation in the VA: https://secure-hwcdn.libsyn.com/p/e/9/e/e9e8859602aa53e8/53_-_A_Common_Message_for_Patients_Dr_Becky_Vogsland.mp3?c_id=20313959&forcedn=attachment&expiration=1524713243&hwt=ca30d9d62b9c4ebe851909cb8088d0ac

        Becky Vogsland shares about the cool stuff going on in Minneapolis!

        Take Care,
        Jessie

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