Effectively Engaging Challenging Patients

You entered the field of Physical therapy with the mindset of helping people heal. You are excited to use your brain, your hands, and your skills to help your patients achieve their goals. As you begin your new career, you feel confident that you are ready to do your job effectively, efficiently and competently. You enjoy people and getting to know your patients as you see them each week, yet you soon realize at times it is not as easy as you envisioned. There are just some patients that make the day a bit harder, slightly challenging, and leave you a bit unsure of how to go about the next session. As a new therapist, the following strategies may be helpful as you navigate some of the most common challenging patients you could encounter in the diverse world of patient care.

The Frustrated patient: This patient is the one who has seen several practitioners before they landed in your PT clinic. They have received countless treatments that, to this point, have not been successful for them. Now they are on your schedule and frankly they are skeptical you are the answer.

Strategy: This patient needs to know you are deeply invested in their care. Be sure to provide them with a clear and detailed outline of your treatment plan. Emphasize that the PT POC is designed by the PT to achieve certain goals, and if these are not being met, the plan can and will be altered. Be empathetic to their journey, listen to their concerns, and reassure them that you will not continue with treatment that is not working. Remind the patient their healing is your utmost concern, and you will certainly refer to other appropriate professionals if you determine the need, or if they request this.

The Political patient: It is never a promising idea to engage a patient in a political conversation during clinical care. Though natural casual conversations are a part of our daily interactions with patients, politics are areas that can be prickly. According to the AMA Code of Medical Ethics1 physicians are called to be sensitive to the imbalance of power in the patient-physician relationship and should refrain from initiating political conversations during the clinical encounter. This ideology relates to the PT/PTA – patient relationship as well. A therapist must be mindful of the possibility that differences in viewpoints can bias us with both the delivery and acceptance of therapeutic interventions. The Standards of Ethical Conduct for the Physical Therapist Assistant 1B states: Physical therapist assistants shall recognize their personal biases and shall not discriminate against others in the provision of physical therapist services.

Strategy: If you have a patient that must discuss the latest political buzz, gently remind them that this is an area of conversation that you do not choose to engage in professionally. Explain that you respect their opinions, but the clinic is not a place to discuss divisive topics and it is best to leave those conversations at the door. 

The Talker: As a new PTA you want to be empathetic to your patients’ needs and want to foster a compatible relationship, but you need to be productive too! You have a busy schedule and have a great treatment plan in mind, but this patient has so much to say, and redirecting them can be a huge challenge to stay on task. 

Strategy: From your first interaction, let this patient know what you plan to do each session, and most importantly, do not ask any open-ended questions! Instead, give them the opportunity to succinctly update their status by using pain scales, questionaries, have them give you one thing that improved since their last session, you get the idea! Get things moving quickly and with each attempted diversion, redirect them to the task at hand. A last resort is to be honest and let the patient know, though you would love to chat, your time with them is limited and you need to focus on the treatment plan so they can achieve their goals. Let them know you look forward to seeing their progress and that they are a priority for you.

The Noncompliant patient: You are so proud of all the work and effort you have put into creating an engaging and effective HEP, only to find out that your patient is not as enthusiastic about it, or even using it, as you had planned! Progress is slow, the patient is sabotaging efforts to get themself well, and you wonder how you will ever get them to the finish line.

Strategy: You know the saying, you can bring a horse to water, but you cannot make them drink. Yet, as therapists we have the benefit of working with clients who understand rationale. The point is, when someone understands the reason you are encouraging an exercise or task, including the benefit that will result (or lack thereof with noncompliance), the better chance you have of getting things accomplished. Some other ways to motivate patients are using apps that show progress or allow you to track their efforts. Use whatever technology they find interesting and motivating, there is so much out there! Being accountable is a wonderful way to help them get on board.

The Inappropriate patient: We are in a field that requires us to touch people, yet unfortunately our clinical skills can sometimes be misinterpreted as an unintended invitation. This is NEVER OK, and as clinicians, we must lay firm boundaries to end even a hint of inappropriateness from the start.  

Strategy: The first line of strategy is to ensure that patients know exactly what you are doing and what manual skills may be performed. Use a professional tone to educate the patient on the expected outcomes and be sure to ask permission before beginning. If the patient comments with any inappropriate language or gestures, let them know immediately that is not acceptable. If the behavior continues, explain that you will need to find another treatment technique to accomplish the goals of therapy. It is that simple, and though may be a difficult skill to develop, it is essential to maintain integrity and professionalism. (Standards of Ethical Conduct for the PTA: Standard #4: Physical therapist assistants shall demonstrate integrity in their relationships with patients and clients, families, colleagues, students, research participants other health care providers, employers, payers, and the public).

Therapists are called to the profession of physical therapy to have a positive influence on the health and wellbeing of others. Our daily work involves interactions with dozens of patients a week, and thousands over a lifetime. The joy of working with a diverse range of patients throughout the human lifespan is rewarding and exhilarating. Yet as with any job, there are challenges that we as therapists must overcome. Arming yourself with a host of strategies in your toolbox of skills will reduce the chance that these challenges will dim the spark that ignited us to be part of the profession in the first place. With all this in mind, go forth and shine on!

1. O’Reilly KB. Patients and politics: What the AMA Code of Medical Ethics says.  January 4, 2018. Accessed July 30, 2024. 
https://www.ama-assn.org/delivering-care/ethics/patients-and-politics-what-ama-code-medical-ethics-says