I recently came upon an internal issue with my own ability to recommend seeking experts in the field of (insert specialty here) to one of my own patients. The context being that a patient of mine (physical therapy) has stage 4 bone cancer and has been and is currently taking a holistic route (mainly nutrition and cannabis treatment) which she has mainly found through the internet. She is seeing me for gait deviation (trendelenberg/lateral trunk sway) which seems to be stemming from a significant hip and lower extremity weakness. Upon further subjective questioning I asked her what all she consumes and she reported that she has no idea what to consume as she has gotten mixed reviews from a lot of resources about what is carcinogenic or not ie meat, sugar, carbs etc. The answer to my question was “mainly smoothies and thai food maybe once a day because I’m scared to eat anything else.”
Now when I asked what her oncologist has recommended she states that she knows more than they do and that she is not in communications with her oncologist. When I asked about the educational background of the people that she is getting her dietary recommendations from (hoping for a registered dietitian) she reports some lady from peru and some website (chrisbeatcancer.com). So not only is she not in communication with her oncologist but she is not getting information from “reliable” sources.
My internal battle is this: with so many providers within the rehabilitation community giving such poor care in the form of language, passive modalities and outdated exercise prescription, I am having difficulty recommending that she go back to her oncologist and her primary care provider and a registered dietitian, even though I still recommended that she see all of those. My hesitation is that if I have difficulty trusting that my patients even see other therapists that I work with due to a lack of keeping up with recent medical and rehabilitation research and practices, how likely is it that other fields also have providers that are not great for patients and are more harmful than helpful.
The reason that I still recommended that she see all of these is that I need to give them the benefit of the doubt that they are experts in their field of practice and truly do know how to help her and will help her. Also all of her needs outside of MSK are outside of my scope of practice and I cannot weigh in on them. So the mix of not having information to give her as it is outside of my scope, hoping that because they went through their specialty and know how to intervene with best evidence, and keeping my patients best interests in mind, I had to recommend that she see them.
TLDR: I dont trust really anyone in healthcare (extrapolating my experience in the physical therapy realm) unless I can somehow see that they are up to date with best evidence so why am I pushing my patients towards seeing “experts” in other fields when I have so much distrust for what comes out of so many other providers mouths. If I cannot trust them why do I expect my patients to?
Sorry for the long post but after reflecting on this I wasn’t sure how to really go about breaking it down
“Also all of her needs outside of MSK are outside of my scope of practice and I cannot weigh in on them. So the mix of not having information to give her as it is outside of my scope, hoping that because they went through their specialty and know how to intervene with best evidence, and keeping my patients best interests in mind, I had to recommend that she see them.”
Your frustration is appreciated. At the same time, you have correctly stated that you can only operate to the best of your ability within your scope of practice. Your patient’s lack of trust in her other health care providers is likely due to a multitude of factors, all of which are outside of your control.
While this was not mentioned in your post, do you feel that you may be inadvertently conveying your level of distrust in these other health care providers in your interactions with your patient? If so, you may be further propagating her lack of confidence in these providers.
In the end, you can only do your best within your scope. The overall management and coordination of this patient’s care, depending on the jurisdiction, lies with her PCP.
While speaking with her, I was definitely trying to bring her back to being agreeable to going to her oncologist and her PCP so that they can shed come consistency and collaboration on her care, although it is very possible I could have been conveying distrust but I did not attempt to agree with her on any level as it would not be appropriate to talk down on a provider with whom I have no experience.
Zooming out from this single interaction, you broadly touched on an important discussion regarding evidence based practice and who to trust. My basic premise is to assume people have no idea what they are talking about until I see the evidence they are substantiating their stance/claim with. I try to vet people before forming a relationship for referral which comes down to time and pertinency of the issue at hand. Hopefully, if everyone is reading and following the evidence then in general we are all roughly arriving at similar conclusions. Meaning we are following the appropriate clinical course of action for issues. This unfortunately isn’t always the case and personally this is likely why I only have a handful of people I’m willing to refer to. In your case though - ensuring a patient in this scenario is receiving care is important; whether you are the person to examine the adequacy of the care is a different story as you seem aware. We have to do the best we can with the best evidence we currently have.
Regarding the word expert - this appears as a societal construct that is bestowed upon a person for any number of reasons and we can even take this a step further and discuss the flaws of titles in society. With that said, trust is a major part of this discussion. Titles evoke a certain level of trust from the general public (right or wrong and we can certainly discuss that), and to reduce this down this hopefully expedites time to interaction and receiving of goods (care) in a timely and cost-effective manner. In general this hopefully works out well for consumer and person providing the service/good.