Mirror, Signal, Manoeuvre

What Can Driving Instructors Teach Physiotherapists About Empowerment?

An unexpected frozen beard is a strangely memorable experience. I had barely cleared passport control and collected my bags at Ottawa International Airport before the beard freeze had set in. As I stood waiting for my Uber outside the terminal building, wintery Canadian icicles began to form around my hairy upper lip. 

Just as my frozen beard had started to spread to my eyebrows my Uber ride pulled up. Out jumped a friendly, warm looking driver. I dived into the back of the car and felt my lip icicles begin to melt. “Where are you from?” he asked. “The U.K. Not far from London.” I replied. Home felt quite tropical compared to here. “Ahh! Welcome to the Canadian winter.” the driver smiled back. 

As we headed towards my hotel he asked me what I was doing in Ottawa in this weather. “I’m a physiotherapist. I am here to teach a course for other physiotherapists.” As he turned to look at me I noticed a peculiar sense of pleasure etched across his face. With a wide, beaming grin he said, “That’s great! I’m having physio at the moment. It’s lovely!” Lovely? What on earth could he mean? After almost thirty years of clinical experience I can honestly say that I have rarely met such a satisfied customer. I had to learn more. What was this wonder treatment? 

As he walked me through his blissful physio experience (the smell of the massage oil, the feel of his muscle knots unknotting, the sound of the whale music on the relaxation tape) I began to feel my defensive, evidence-based hackles stand to attention. “So, is this the sort of physio you’ll be teaching here in Canada?” he asked. Oh blimey! How do I answer this one? I didn’t want to be ‘that’ finger wagging physio. Then it hit me. 

“Well, there are different ways to think about physio.” I said whilst biting my frozen lip trying hard not to think about the whale music comment. I asked him if he would mind if we tried something. “Sure. Fire away.” he said. “Okay. Here goes. I’ve got three questions for you…”

Question 1: 

“How long have you been able to drive a car?”

Answer 1: 

“Er, a bit more than 20 years. Actually, it’s been 24 years since I passed my driving test.” 

Question 2: 

“Great. How many lessons did you have when you were learning how to drive?”

Answer 2: 

“Hmmm. I can’t remember exactly but I think it was about 15 lessons.” 

Question 3:

“Okay. Final question. How many times have you needed the driving instructor since you passed your test?”

Answer 3: 

“I haven’t. I don’t need the driving instructor anymore. I learnt how to drive and now I’m able to do it.” 

Maybe it was the cold. Maybe it was the jet lag. Whatever it was, I seemed to have found a way to communicate a fundamental difference between the ‘lovely’, if not somewhat passive approach to physio my driver had experienced, and the active, empowering approach to physio that I was aiming to teach whilst visiting a very frozen Canada. 

The World Health Organization ^[1] define empowerment as “a process through which people gain greater control over decisions and actions affecting their health which can be obtained through skill development, access to information and resources and influencing those factors that affect their health and well-being.”

I realised something in that moment. Perhaps physiotherapists could learn something valuable from driving instructors? Driving instructors are the Jedi Masters of empowerment. They quite literally give control to their students. If we compare this to the evidence regarding patient empowerment in healthcare, we begin to notice a worrying disconnect between the empowerment patients want and the disempowerment patients all too often get. 

Following several years of interviewing clinicians, researchers and people living with pain, the healthcare journalist Judy Foreman ^[2] concluded that, “There is an appalling mismatch between what people in pain need and what healthcare professionals know.” 

To understand one of the possible causes for this mismatch, we first need to reflect on how clinicians are trained. Briggs et al ^[3] found that in many healthcare disciplines, communication and patient education skills accounted for less than 1% of undergraduate programme hours in the United Kingdom. This suggests that the remaining 99% is dedicated to learning anatomy, physiology, pathology and biomechanics. 

These things are, of course, important for any student healthcare professional to learn. However, driving instructors don’t focus 99% of their training on the intricate workings of the vehicle’s engine, suspension and transmission. Instead, they understand the importance of guiding people towards self-efficacy.

In the years that have passed since my Canadian Uber experience, I have been using these same three questions with patients. I have found it to be an engaging, thought provoking and non-judgemental way to assess how ready people are to actively participate in their care. 

When asking these questions I have noticed a range of reactions. Some will politely nod along before enquiring when the massage is going to begin. However, many will return to clinic having reflected on how this idea applies to their healthcare experiences. Some recount how they have wasted time, money and energy stuck in the passenger seat. Some have been through a rehabilitation journey where they have never left the back seat. Others feel like they’ve been trapped in the rehabilitation boot. All have been chauffeured around in a state of what the educator Daloz^[4] has called ‘stasis’. 

Stasis refers to a learning experience where the learner encounters a low amount of challenge, and a low amount of support. From the passenger seat, back seat or boot of the rehabilitation vehicle there can be no impetus for development. Nothing much happens. Things stay as they are. These tales of frustration and disempowerment are unfortunately not only common in practice.^[5] They are also reflected throughout the research. ^[6,7] The following excerpt  illustrates this point: 

“She told me that the high point of her life was playing the organ for her church choir. She lived for the twice-a-week practices and Sunday performances. Now, with pain immobilizing her elbow, she could no longer manage the keyboard. Her days held nothing that she looked forward to. The constant aching had robbed her of any hope. Life seemed empty of everything except pain. When I asked her if she had explained this to the staff in the clinic, she replied that they had not asked. Her medical history, as one might expect, read exactly like the history of an elbow.” ^[8] 

A couple of things have always stood out for me about this statement. 1) The complete disconnect between the patient’s values and the clinician’s biomechanical focus, and 2) The mistaken assumption I often encounter when teaching about this statement: Physiotherapists will regularly shrug and suggest that, “This lack of empowerment doesn’t happen now though. Things have surely moved on since 1991. Haven’t they?” 

Let us explore this hazardous blind spot assumption by turning our attention towards more contemporary evidence. Hickmann et al^[9] found that clinicians need to foster tailored, active patient engagement if they are to help patients to become active partners in their personal healthcare. Padfield et al^[10] suggest that an inherent dilemma exists in many clinical consultations with clinicians and patients searching for separate goals with separate meanings. Jones et al^[11] found the main obstacle to achieving a more collaborative, empowering therapeutic relationship through effective communication skills seems to be the clinician’s compelling desire to treat and advise the patient. 

This finding is somewhat ironic in that it suggests the more clinicians try to fix the problem, the less likely they are to empower people. Equally, the more the driving instructor insists on keeping a tight grip on the steering wheel, the less the learner learns from the passenger seat. 

We all have blind spots. We don’t learn from experience. We learn by reflecting on our experiences. With this in mind, the following reflective exercise provides an opportunity to examine how much control we are prepared to offer patients. 

Figure 1: Clinicians’ empowerment rationales.

Reflective exercise: 

Read & reflect on the following statements. What are your thoughts? Do you recognise these rationales in your practice? Have you overheard similar ideas within clinics? What do you notice about the words that are used within the statements? 

• “I have to say I don’t particularly ask the patient what they want. I think giving them so much choice, they can often get confused. It is almost too much for them.” Clinician

• “I must admit for every patient I have coming in through my door, I pretty much will always give them exercise. I don’t think about it too hard, it’s just part & parcel of the package that I like to give.” Physiotherapist

• “Overall, the physical assessment plays a very large role in the choice of exercises. I tend to work out what I think is best.” Physiotherapist

Adapted from ^[12]

Stenner et al^[12] used semi-structured interviews to explore how physiotherapists collaborate with patients. The findings revealed a lack of patient-centred practice with the participating physiotherapists making assumptions about what was best for the patients. 

Perhaps most strikingly, the word which appears most is ‘I’. Communication throughout physiotherapy consultations has been found to be predominately therapist-led and paternalistic with patients left feeling disengaged^[6]. This approach to communication is at odds with best practice^[13]. Furthermore, Scott-Dempster et al^[14] used Interpretative Phenomenological Analysis (IPA) to explore the meaning physiotherapists gave for paced exercise prescription. They concluded that physiotherapists need to ‘shift from a fix it to a sit with it mindset.’ 

After years of steering patients where I wanted to take them, something had to change in my practice. My Masters degree in education was the catalyst for this change. It helped me realise that I’d been trying my best to empower and educate people, but without the necessary knowledge and skills to optimise this empowerment and education. 

Let us try something. I have two questions for you to answer:

1. Raise your hand if you teach people things every day in your practice? (This does not have to involve plunging the depths of pain neuroscience education. It might involve teaching people how to do an exercise or how to use a walking stick). 

2. Now raise your hand if you were taught how to teach? 

Having spent ten years asking these questions to clinicians around the world, I am assuming that the majority of you reading this only raised your hand for question 1? 

Dreeben^[15] argues that patient education forms ‘a significant component of modern health care.’ Yet, despite this, educational skills are merely assumed in healthcare settings with many clinicians having a limited toolkit. ^[16,17]

If healthcare professionals are teachers without teaching skills, this suggests a fundamental dilemma. Without an understanding of the complexities of education, clinicians will likely remain unable to empower their patients. Without teaching skills we are unlikely to recognise the delicate, dynamic balance that exists between how much to challenge people and how much to support them.^[4] Equally, we cannot begin to comprehend the reasons why patients sometimes become blocked when attempting to learn something new. ^[18] 

The Latin word for education is ‘educare’ meaning ‘to draw out that which lies within’. Empowerment begins with an understanding that the answers to people’s problems often lie in their words, not ours. Or, as Socrates would say, “To find yourself, you must think for yourself.” 

When learning to drive, we are taught a clear three step process when beginning any journey. In order to safely guide their learners to move forward the driving instructors mantra is:  mirror - signal - manoeuvre. I would suggest that a helpful equivalent in healthcare is to  listen - find out what people want - guide them. 

If physiotherapists are to empower vulnerable people living with pain, we must first be prepared to lose some of our own power. For the patient’s power to rise, the clinician’s power has to fall. Like the driving instructor, we need to learn to relinquish control and give the patient the steering wheel. 

References

1. World Health Organization. (2013). Health 2020: a European policy framework and strategy for the 21st century. [11/05/2018];World Heal Organ. 2013 182 [ http://www.euro.who.int/__data/assets/pdf_file/0011/199532/Health2020-Long.pdf] [Google Scholar]

2. Foreman J (2014) A Nation in Pain. Healing our Biggest Health Problem. Oxford University Press, London.

3. Briggs, E, Carr, E, Whittaker, M. (2011). Survey of undergraduate pain curricula for healthcare professionals in the United Kingdom. European Journal of Pain. 15 (8) 789-795.

4. Daloz, L. (1999). Mentor: Guiding the journey of adult learners. San Francisco. Jossey-Bass.

5. Dow, CM, Roche, PA, Ziebland, S. (2012). Talk of frustration in the narratives of people living with chronic pain. Chronic Illness. 8 (3) 176-91.

6. Dierckx, K, Devugele, M, Roosen, P, Devisch, I. (2013). Implementation of shared decision making in physical therapy: observed level of involvement and patient preference. Physical Therapy. (10) 1321-30.

7. Elwyn G, Hutchings H, Edwards A, Rapport F, Wensing M, Cheung WY, Grol R. (2005). The OPTION scale: measuring the extent that clinicians involve patients in decision-making tasks. Health Expectations, 8: 34-42.

8. Morris, DB. (1991). The Culture of Pain. University of California Press. Berkeley.

9. Hickmann, E, Richter, P, Schlieter, H. (2022) All together now – patient engagement, patient empowerment, and associated terms in personal healthcare BMC Health Serv Res. 2022; 22: 1116.Published online 2022 Sep 2. doi: 10.1186/s12913-022-08501-5

10. Padfield D, Janmohamed F, Zakrzewska J, Pither C, Hurwitz B. (2010). ‘A slippery surface: Can photographic images of pain improve communication in pain consultations?’ International Journal of Surgery. 8 (2):144-150.

11. Jones, L, Roberts, L, Little, P, Mullee, M, Cleland, J, Cooper, C. (2014). Shared decision making in back pain consultations: an illusion or reality? European Spine Journal. 23. 13-19.

12. Stenner, R, Swinkels, A, Mitchell, T, Palmer, S. (2015). Exercise prescription for non-specific chronic low back pain (NSCLBP): a qualitative study of patients’ experiences of involvement in decision making. Physiotherapy. doi: 10.1016/j.physio.2015.08.005

13. Elwyn G, Hutchings H, Edwards A, Rapport F, Wensing M, Cheung WY, Grol R. (2005). The OPTION scale: measuring the extent that clinicians involve patients in decision-making tasks. Health Expectations, 8: 34-42.

14. Scott-Dempster, C, Toye, F, Truman, J et al., (2014). Physiotherapists' experiences of activity pacing with people with chronic musculoskeletal pain: an interpretative phenomenological analysis. Physiotherapy theory and practice, 30 (5), 319-328.

15. Dreeben, O. (2010). Patient Education in Rehabilitation. Sudbury. Jones & Bartlett.

16. Bolton, G. (2010).  Reflective Practice. Writing & professional development. 3^rd edition. London. Sage Publications.

17. Hinchliff, S. (2004). The practitioner as teacher 3^rd edition.  London. Churchill Livingstone.

18. Morrison, T (2001) Staff supervision in social care. Brighton: Pavilion Publishing.