Case of the Month
The Case
The College received a complaint from a patient about the care they received from a physiotherapist. The patient had attended several appointments with the physiotherapist to treat a knee injury and did not experience any issues until the final appointment.
The patient said their previous appointments were consistent. They always completed the same stretching and rehabilitation exercises in the open gym area before the PT placed electrode pads on the patient’s knee for approximately 10 to 15 minutes. During this time, the physiotherapist always left the patient alone.
During the final appointment, the patient felt like everything had changed. The physiotherapist had the patient complete their stretches in a private treatment room with the door closed. The PT also introduced new stretches where the physiotherapist’s hand was placed high up on the patient’s leg, near their groin. The patient also said the physiotherapist leaned in heavily while performing a figure four stretch, so the PT’s face was very close to the patient’s face, which had never happened before.
The patient was uneasy with these changes but did not feel comfortable saying anything. The patient didn’t recall the physiotherapist providing an explanation for changing the exercises or performing them in a private treatment room instead of the open gym.
The patient also mentioned to the physiotherapist that their abdominals were sore, and said the PT proceeded to touch their lower abdominal region without getting the patient’s consent. Finally, the patient said the physiotherapist sat beside them for the entire time the electrode pads were on their knee during the final appointment, attempting to make conversation with the patient, which made the patient uncomfortable. At the end of the appointment, the patient cancelled all future appointments and did not return to the clinic.
The physiotherapist maintained that the changes to the exercises were clinically indicated. The PT also noted that they moved the patient to a private treatment room because another patient was using the open gym area. The physiotherapist apologized for making the patient feel uncomfortable but said there was no indication of discomfort from the patient during the appointment. The PT also acknowledged that they assumed the changes would be fine, and they should have made more of an effort to obtain informed consent.
The Standards
Based on a thorough review of the clinical notes, all treatment appeared to be clinically indicated. The issues in this case are related to the lack of communication, consent and documentation. The explanations provided by the physiotherapist for changing the treatment plan or moving the patient to a private treatment room appeared to be reasonable, however these explanations weren’t clearly communicated to the patient.
As stated in the College’s consent resource, physiotherapists must be sure that patients understand the nature of the treatment, its benefits, risks, side effects, alternative courses of action, and any possible consequences of not having the treatment. PTs must also answer the patient’s questions and document their conversations about consent in the patient’s chart.
In this case, there were several instances of documented consent in the patient’s chart, but there were gaps in documentation related to the final appointment. For example, there was no evidence of a conversation around moving the patient to a private treatment room, updating the exercises or getting the patient’s consent to touch the lower abdominal area. To help support the patient in making informed decisions, any changes to treatment should have been discussed.
Additionally, physiotherapists are responsible for maintaining not only the physical safety of patients throughout treatment but their psychological safety as well. By making assumptions that the patient would be ok with an approach that was out of the ordinary or doing exercises in a private treatment room with the door closed, the PT negatively impacted the therapeutic relationship.
As outlined in the College’s communication skills resource, communication is an essential skill in supporting a patient’s physical and emotional wellbeing. The Patient Centred Communication E-Learning Module provides excellent guidance for recognizing and addressing a patient’s non-verbal communication and using various techniques to help address uncomfortable situations.
The Outcome
The physiotherapist acknowledged areas of improvement in their practice and agreed to participate in a practice enhancement program with a College-approved coach. The program will focus on communication, obtaining consent and record keeping.
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