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The Four Laws of Quality Care, Law II

Welcome to the second installment of my four-part series on The Four Laws of Quality Care.

They are so-called because I believe these four components encompass quality care at every stage. Law I is all about rapport and can be found here.

Let’s jump right in to talk Law II:

Transparently investigate their primary concern, including symptom modification whenever possible.

There’s a lot in here, so we’ll break it down into 3 parts:

  1. Primary concern

  2. Transparent investigation

  3. Symptom modification

Primary Concern

It’s not people’s symptoms that bring them in; it’s their concerns about their symptoms that bring them in.

It’s important to realize why people really come to see us. There are a lot of people out there who have pain or other symptoms but never seek care because they’re simply not concerned enough.

Of course, we want to address people’s symptoms, but when we additionally understand their concerns, we can address the symptoms in the manner in which they matter to the person.

I’ve seen this come up a lot, especially when it comes to things like surgery:

A person comes in with pain and limited shoulder range of motion (ROM) and is concerned that they have a rotator cuff tear. So, over the course of 4 sessions, the physical therapist helps them to reduce the pain and improve their ability to reach. They’re 90% improved. But then the person cancels their remaining visits because they decided to get a rotator cuff repair surgery. The therapist is left scratching their head.

This can be perplexing, but if throughout the duration of care the person was concerned that they would need surgery or else it would keep getting worse, merely addressing their symptoms and function might not actually be that meaningful to them. The extra step needs to be taken to address their concerns directly.

The other important point is finding out their primary concern.

This is extremely useful for helping us focus on what’s most important to them first. Many people have several concerns, so finding out their main concern can help to focus early on, so that changes can be made early on as well.

So, how do we find out the person’s primary concern? We ask, “... At this point, what is your primary concern?

Transparent Investigation

After determining what the person’s primary concern is, the next step is investigating this concern as part of the examination.

The idea here is to do our typical exam, so that we can get the information that we need while adapting it to thoroughly investigate their concern as well.

There are many reasons to loop the person in during the exam:

  1. It puts them at ease when they understand what we’re testing and why. Think of a time you saw a healthcare provider who did a bunch of stuff and didn’t explain anything to you until the end (if at all). Now compare that to a time when the healthcare provider explained everything that they were doing as they were doing it. Which one put you more at ease?

  2. It allows them to give us more information. Some of the most useful information I’ve gotten from patients was during the physical exam, not during the history. This is because during the exam we end up doing some of the things that they have trouble with, not just talking about it. This tends to be when the really juicy contextual information comes out.

  3. It helps them learn better. If our goal is to help our patients come to a more helpful understanding of what’s going on and how to problem-solve through it, showing them can help tremendously with this. There’s nothing wrong with telling people things, but I believe if we really want to help people learn, we need to show them. We’re all like this: we need to see for ourselves in order for us to really get it.

Here’s what often happens when we don’t loop the patient in:

We spend 20 minutes or so doing a bunch of testing, not explaining what we’re doing or why. The person doesn’t really seem to understand the process, but we press on because we need the information. Then we sit down and explain to the person what the problem is. They don’t seem to get it, and we can’t understand why. They were there when we were doing the testing, so why don’t they get it?

They don’t get it because we didn’t explain it to them. They’re not PTs, so they don’t understand what all the testing means or how it applies to their problem or their life. Transparent investigation calls us to investigate the problem with the person—to bring them along, so that we get better information and they actually understand what’s going on.

Implicit in this step is taking their concern seriously.

We often subtly (or not-so-subtly) inject our own views and opinions about what is a reasonable complaint into the situation. And I say we because I do this too.

It’s important to remember that it’s not our job to judge the worthiness of people’s concerns. It is our job to investigate their concerns with them to see if we can help.

Let’s talk through an example of what the transparent investigation might look like…

Let’s say a person comes to you with a diagnosis of hip osteoarthritis (OA). Their main concern is that they’ll need a hip replacement, and their friend had a hip replacement a year ago and still hasn’t gotten back to full function.

Knowing their primary concern, you skillfully narrate the exam:

  • You preface screening the lumbar spine with, “So let’s check to make sure your back isn’t contributing to this hip pain you’re having…”

  • You frame hip mobility testing by saying, “So let’s see how your hip joints move.”

  • You check the uninvolved side. “So this is about how much the other one should move, so let’s see how it compares…”

  • You check the involved side, and it moves the same, “OK, so the joint moves well. That's a great sign. Let's keep looking to see what might reproduce some of this pain you’re having.”

  • Then you end up reproducing their symptoms with resisted isometric testing. “So this is your pain, huh? This is good news: your hip joint moves well and doesn’t bring on your pain, and instead, we can reproduce your pain by testing your muscles*. This tells me that you likely will not need surgery and would do well with some simple strengthening exercises. What do you make of that?”

In this case, you knew there was a diagnosis given of hip OA causing concern about a surgery. You investigated all that with them, found that the pattern doesn’t quite fit with hip OA, and told them that surgery is likely not indicated. Well done.

But let’s say when you test mobility the hip is limited/painful in the classic OA pattern.

  • In this case, you say, “Hmm, yeah, I see what you mean. This is your pain, huh? OK, let’s look at a few other things, and then we’ll try some treatment and see how you respond. I’ve seen a lot of people with a problem just like this who got better without surgery.”

In this case, you’re still addressing the primary concern of surgery, but in a slightly different way. We’ll circle back around to this example during the symptom modification section, which is next.

What we’re really doing in this process is gathering evidence and relating it all back to their primary concern.

Throughout this case, we framed things from more of a diagnostic standpoint because their concerns stemmed from this structural diagnosis they were given of hip OA**.

If we skip this step (of showing people) and just start spewing information about asymptomatic OA prevalence or pain science on them, it probably won’t go so well. This is because we haven’t proven what we’re saying in any way.

If you don’t prove it, why should the person believe it?

Symptom Modification

So, we’ve talked about transparently investigating their primary concern, and now we’re going to finish by talking about symptom modification.

Symptom modification refers to anything that modifies a person's symptoms, things like:

  • Movement modification***

  • Assistive tests

  • Manual therapy***

  • Loading

  • Breathing, threat reduction, etc.

One of the best ways to give somebody hope is to show them that their problem is changeable.

One of the most distressing aspects of pain is not knowing how to control it or not believing that it can get better. Including symptom modification is an extension of this concept of ‘proving it’ to the person.

When we can show the person that their problem is changeable, they personally experience the possibility of relief. This tends to stick much more than only telling people that they can improve.

Let’s go back to our example from above where the person’s clinical presentation does fit with OA.

Realize that this doesn’t need to be denied, nor do we really need to start out by educating them about imaging and OA or pain science. We really just need to find out if PT will help and if they’re willing to give it a try.

We know that there is good evidence for conservative care for OA, so we could share that with them, but we really just need to try it and see. This is where symptom modification comes in.

Maybe we modify their movement, maybe we perform manual therapy, maybe we have them load the region through exercise. Either way, we retest afterwards to see if changes were made. If so, this is some proof for the person (as well as for us) that PT is likely to help them.

Once they're on board and our relationship strengthens, we can layer information about pain science as well as the relationship between imaging findings and symptoms. As discussed about the person’s symptoms vs. their concerns, it’s likely not the diagnosis itself that is concerning—it’s the implications.

If we can show people that things can change, they are more likely to give it a go.

Give this a shot with one of your next new patients:

  • Find out what their primary concern is

  • Investigate that concern with them by narrating the exam

  • Perform symptom modification procedures during and/or after the exam and see if any changes are made

  • Relate the findings of the exam and treatment to their primary concern in your explanations

In Summary:

  • It’s not the person's symptoms that bring them in; it’s their concerns about their symptoms that bring them in

  • Take the extra step to address people’s concerns directly. Addressing only symptoms and function isn’t always enough

  • We must take the person’s concerns seriously to adequately investigate them

  • If you don’t prove what you’re saying, why should the person believe it?

  • One of the best ways to give somebody hope is to show them that their problem is changeable

Thank you so much for reading. I’d love to hear from you! Please let me know your thoughts in the comments below, and share with those who you think would enjoy too!




*Of course we know things aren’t as cut and dry as the examples I gave—we can’t only test the joints/muscles/spine. But keeping things as simple as possible, I believe, is the best place to start. We can always add more details if they want to know, but if we make it too complicated from the beginning, it’s harder to come back from that. Graded exposure applies to information as well.

**The other thing to note here is that depending on the person and the presentation, the language will vary. If we pretend this person has severe widespread pain without clear aggs/eases, it may be the case that everything we test reproduces their pain to some extent, or maybe nothing we test reproduces their pain. This too is good evidence that hip OA is likely not the main issue, but again the concept tends to stick when we can show the person before we discuss it with them.

***You may already know that there’s a lot of debate out there about things like manual therapy and movement modification. I believe that it all comes down to how you frame what you’re doing. When we change the way somebody moves, load tissues, push on a joint, and it changes someone’s symptoms:

  • We can use this as evidence that we're amazing, and they need to come see us 3x/week for life

  • OR,

  • We can use this as evidence of the body’s innate capacity to heal and change.

It’s all how we frame it.

Click here to dive right into Law III & continue the fun!

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