“I’m going to walk out of here without a walker, without a crutch, without a cane — without any of that.”
A patient told me this during his evaluation in inpatient rehab. It was three days after his total hip replacement. Considering that he was still struggling to walk with a walker, I remember appreciating his optimism even though I may have doubted his prediction. It was the first week of my internship, so I had the opportunity to work with him until his discharge. I was excited to see how well he would progress, not just because I cared about his improvement in therapy, but also because I was curious about whether he would meet his ambitious goal.
He was right. I was wrong. “I told you I wouldn’t need any of that stuff,” he told me right before his discharge.
The day my patient was discharged, I learned an important lesson about the power of setting goals. I felt that merely the act of telling me his goal made it more likely that he would achieve it. If he had not told me his goal, then I probably would have set different goals for him, like being able to walk with a cane instead of a walker. He had a higher goal in mind, and I simply wouldn’t have known about it if I hadn’t asked him.
There is a temptation in physical therapy to set goals for patients without including patients in the process. On one hand, there is actually some evidence that assigning goals to people (i.e., instead of allowing participation in goal setting) might not necessarily lead to worse performance, so long as the goals are important enough to the person trying to meet them (Locke & Latham, 2002; Latham, Winters, & Locke, 1994).
There are are several risks to assigning goals to patients without their participation, however. One problem is that the goals of the physical therapist aren’t always important to the patient. How many people really care about hip circumduction or thoracic kyphosis? If we can educate people to explain why they should care, then that’s one way to improve performance, but we still might be missing the forest for the trees. We still might miss the patient’s higher objective.
I first heard about the idea of a higher objective from an episode of the Healthcare DisruPTion podcast, in which Jerry Durham and Andrew Rothschild interview Matt Watkinson — author of The Ten Principles Behind Great Customer Experiences. Durham, Rothschild, and Watkinson talk about many ways that physical therapists can improve the customer experience for our patients. One of the biggest mistakes that we make in healthcare is that we overlook what’s actually important to our customers. People want to be in less pain, to play a better round of golf, or to walk out of the clinic without their walker. As Theodore Levitt said, “People don’t want to buy a quarter-inch drill, they want a quarter-inch hole in the wall.”
In her book Grit: The Power of Passion and Perseverance, Angela Duckworth talks about how our goals should fit within a hierarchy. Our top-level goal should be an ultimate purpose, whether it is related to our health, family, or career. Dr. Duckworth writes that we should have several mid-level goals to support to top-level goal, and several low-level goals to support our mid-level goals. As physical therapists, we might know how to write low-level or even mid-level goals for our patients, but only our patients can write their top-level goals — their higher objectives.
Since we can’t telepathically know our patients’ top-level goals, then what good is a patient evaluation without asking about goals?
If I hadn’t asked about my patient’s goals, then I would have been satisfied with the goal “to ambulate 500 feet with least restrictive assistive device.” I would have missed the point, though. He didn’t want any of that.