When considering medical clearance for participation after injuries, there are numerous components to take into consideration to ensure physicians act within the standard of care, and that they keep patients’ best interest in mind. In this month’s episode, Steven and Yolanda discuss the precautions and responsibilities of both parties in assuring a safe return environment. The duo highlights the importance of shared decision-making to establish an efficient framework.
Announcer: You're listening to CMPA: Practically Speaking.
Dr. Steven Bellemare: Hello, everyone. Hi, Yolanda.
Dr. Yolanda Madarnas: Hey, Steven.
Steven: How are you?
Yolanda: I'm well thanks. How are you?
Steven: I'm well, I'm well. Listen, Yolanda, have you ever had to fill out any paperwork for patients?
Yolanda: Oh, way too many times.
Steven: Of course you have.
Yolanda: It's - it's, yeah.
Steven: Who hasn't, right?
Yolanda: Yes, yes, yes.
Steven: What's one of the themes that you think comes up frequently that causes some concern amongst physicians?
Yolanda: Well, many times these forms are in the setting of someone either absent from work or absent from one of their activities, be it a professional activity or a hobby. Then, it involves giving the green light or the go ahead for a return to those activities.
Steven: Right.
Yolanda: Be it sports activities, or back to work.
Steven: That's what we thought we'd talk about today is in fact return to play.
Yolanda: I think that's…
Steven: Return to work, return to activities. While most of you don't have patients who are professional athletes I'm sure, chances are that you will see some patients in your practice who will need clearance to return to sport, or return to work, or some other type of activity.
Yolanda: Today's podcast really complements the article on the fitness to participate, but really it's essentially clearing a patient to return to an activity.
Steven: Why do we worry about this?
Yolanda: Well, there's a concern among physicians about liability if your patient is re-injured or relapses from the condition they were off for, and there's a concern among physicians as well about, "Well, what if our patient doesn't follow the advice and the constraints placed for this return to work?"
Steven: Right. There's also fears about managing uncertainty, so are you making the right decision, especially if it's not a decision that aligns with what your patient really wants. The secondary agenda that patients or parents of younger patients may have and the ensuing relational problems if you end up making a recommendation that they don't quite like.
Yolanda: Returning patients to active participation, be it in sport, or hobby, is really rewarding, but it's important to balance this against the competing interests, so really the desire to return to activity versus the safety of that return.
Steven: This is a really emotional issue, isn't it?
Yolanda: Yeah.
Steven: Lots of people may apply lots of pressure, and I think the theme from the podcast will be stick to your basic principles as a way to hopefully make the right decisions and stay out of trouble.
Yolanda: Emotions can run high with our patients who are athletes, their parents, their coaches, their team members.
Steven: And insurance companies, employers, the parents themselves, right, all able to exert some significant pressures on us as physicians.
Yolanda: Recognize that you're not alone in this, so drawing upon collective expertise of other healthcare professionals involved in that patient's care can really be a helpful approach to manage these situations.
Steven: What would be our key messages for today, Yolanda?
Yolanda: Well, I think first and foremost stick to the basic principle of keeping your patient's best interests and safety in mind as the driver for those decisions about returning to activities, despite competing interests.
Steven: Right. Number two, ask for help if you're not sure what the latest guidelines - or if you're uncomfortable with the nature of the illness or the injury that you're dealing with and the implications for returning to activity.
Yolanda: Our third takeaway, it's really important to remember to include discussions about short-term and long-term risks of a potential return to activity in your discussions with your patients.
Steven: Let's take take-home message number one then, keeping the best interest of our patients in mind. What does that mean?
Yolanda: Well, it goes without saying that these decisions have to be taken with great care, and first, an issue we see in many cases though is the thoroughness of the assessment. It's helpful to remind ourselves to be mindful of our scope of practice, and our experience with that particular condition.
Steven: Really, it's about knowing what you're talking about and having an approach, whether you're dealing with something high stakes like an exercise-induced syncopal patient with a positive family history of sudden cardiac death, or something perhaps a little bit more mundane like a twisted ankle, sprained ankle. The basic principles are the same in coming to a decision, right? Act within the standard of care. Take a history, do a physical exam, consider the risks and benefits, and discuss those with the patients.
Yolanda: Absolutely. Remember as well that physicians are held to a standard of means, not a standard of results.
Steven: Well, that's an interesting concept. I think that's the first time we talk about that in our podcast.
Yolanda: I think so.
Steven: What do we mean there?
Yolanda: It means that the courts and the regulatory authorities don't expect perfection from us. They don't expect us to guarantee a good outcome. Rather, they expect us to come to our decisions and our recommendations in a diligent manner, as a result of a sound decision-making process that meets the standard of care.
Steven: In the end, we're not infallible, and it's hardly ever, if at all, possible to offer any guarantee. Finding that threshold of safety is the key, right? It involves some element of judgment on your part and on the patients, and that speaks to peoples’ risk tolerance as well.
Yolanda: That also is shared decision-making.
Steven: Right. I have to say, don't be fooled by the "seemingly mundane low-stakes situation." Right? Your approach - and that means being systematic, is the key to ensuring you do your due diligence and adhere to a recognized standard of care.
Yolanda: Whether it's a big injury, a serious injury, or more mundane run of the mill injury, keeping your patient's best interest at heart is the key, and that really takes us to take home point number one.
Steven: You may face tremendous pressure to make the "right" decision for you patient, but that may not be the right medical decision.
Yolanda: Yes.
Steven: We need to balance those two things.
Yolanda: Absolutely. Let's consider, so what the patient feels is the right choice. What the coach feels is the right choice. What the employer feels is the right choice. What an insurance company might feel is the right choice.
Steven: Don't always align with what you think is medically the right choice.
Yolanda: Yeah. Right, and this is where sticking to accepted criteria, an approach, and a standard of care is really important.
Steven: It's the opportunity to draw upon the collective expertise to see clearly through these competing interests.
Yolanda: It's not unusual for patients to insist to return to play, for example, or the corollary to stay away from work, even though you see things otherwise, and your recommendations are counter to those.
Steven: Right, but that doesn't mean you must do what your patient wants necessarily.
Yolanda: Yeah. Sure. They have to consent to the way forward, and ultimately it's their choice, but it's particularly important when your advice is contrary to what they want to do.
Steven: You need to stand on something solid, and that's knowing and adhering to the standard of care in terms of how you went about doing your assessment and how you came about for your recommendation.
Yolanda: For instance, taking an approach using algorithmic decision-making models from the literature can really help guide you in your decision-making process but can also serve as an educational tool for your patient, explain why you're basing your decisions on this evidence.
Steven: That's right. It's a powerful thing to actually be able to take the algorithm and follow it in person with the patient together to say, "See, you answered yes. That means we have to go there as opposed to there, and therefore the decision." That takes some of that subjectivity away.
Yolanda: Absolutely.
Steven: The literature, you know, talks about decision modifiers, such as proximity to play offs, or the presences of a university scout, for instance, as a significant pressure that physicians can face in returning a player to the game, for instance.
Yolanda: When those are at play, you really need to be careful to document your rationale and decision-making process for whatever recommendation you make.
Steven: Even the patient's best interest can be a grey area.
Yolanda: Yes, it can. Let's use a sports example. Your patient may think going back to play is in their best interest, but you see it differently. For you, for your patient making it to the big leagues, for example, may be their priority, whereas for you, your concern is about not developing osteoarthritis in their 20s or turning an acute injury into a chronic problem.
Steven: That's right, and so we've talked about it in our other podcasts, exploring the patient's feelings, interests, function, and expectation - what we call the FIFE model, becomes very important.
Yolanda: Doing so in the end, using such an approach can really help you build a strong alliance with your patient, and in the end, you can agree to disagree.
Steven: That's right. Okay, second take home message; don't be afraid to ask for help.
Yolanda: Absolutely. There are numerous healthcare professionals often involved in the care of our patients. For example, a physiatrist might know the ins and outs of a given injury much more than you.
Steven: While the patient may be coming to you to fill out a form, it may be that an orthopod or a physiotherapist that are involved in the patient's care may actually be better placed than you to opine on the return to play.
Yolanda: These are really valuable resources that you shouldn't hesitate to leverage.
Steven: You know, but that said, we have to be careful not to punt them all to these other resources, because you have to consider your long-term collaborative relationships. When we do hear on the phones sometimes that there are…
Yolanda: Tensions.
Steven: …there are tensions, exactly. Some people who are kind of "known to always send these types of things to colleagues," and you definitely want to be mindful of the collaboration.
Yolanda: I mean, you are fundamentally the most responsible physician. You are the patient's treating physician, so you're a central point, and no one likes to be dumped on.
Steven: No.
Yolanda: It's still helpful to consult with these colleagues, a phone call, an email, a letter saying, "This is what I'm facing. What are your thoughts on this?" It's a joint decision. You didn't pull this out of a hat. You've taken this together, again, in your patient's best interest.
Steven: We just need to make sure we're judicious when we do that.
Yolanda: Remember, these interprofessional relationships can really be valuable, and don't hesitate to tap into them when something feels off, or when you're out of your comfort zone in the management of a condition. For example, there are physiotherapists who specialize in concussion rehab and management of post-concussion syndrome and can be an invaluable resource to help you help your patient in these return to work or play decisions.
Steven: Yeah, and when we consult our colleagues and seek their advice, we have to be mindful and remember that not all advice is formal, in fact.
Yolanda: Absolutely. You know, a phone call or an email to the neurologist or to the physiotherapist can be invaluable in helping you assess and manage the situation.
Steven: It's important to take note of that, because it forms part of demonstrating your diligence in coming to that recommendation.
Yolanda: Absolutely, and the same goes the other way. If you receive a call from a colleague who seeks your advice, again it's perfectly fine to give advice over the telephone, remaining mindful of your duty of care to the patient.
Steven: That's right, and I was going to say it's important though to take notes of those informal consults and indicate what points you considered in making your recommendations, because you can be sure the other person - the one who called you for advice, will have noted in the chart that they called you.
Yolanda: Absolutely.
Steven: Yeah.
Yolanda: This takes us to our third take home point. Remember to have fulsome discussions about the potential risks of return to work or return to play with your patient and to document these carefully in your record.
Steven: Shared decision-making is important, and for instance, it's important to remember to include, for instance, any potential long-term risks that may be incurred with a return to play too early.
Yolanda: In the end, we have to recognize that it's up to the patient to weigh those risks and benefits of a return to play…
Steven: Right.
Yolanda: …and take into account their personal preferences and values.
Steven: You're making a recommendation, but it may or may not be followed.
Yolanda: For sure, and this isn't a new concept in medicine, right? It's not uncommon for patients not to follow our recommendations in any number of aspects. Steven, let me ask you, we often hear people talk about clearing a patient, but can we really ever clear someone?
Steven: Yeah, you're right. It's a matter of an informed decision on the part of the patient, I think, based on your recommendation, and this is why the article mentions that you may not want to sign a blanket clearance certificate to say, for instance, that a person is fit to fly or fit to leave the country for three months. Rather that you write a statement about the stability of the condition and the risks as you see them at that time.
Yolanda: It's important to ensure the patient understands that it's their decision to make, based on your professional recommendations, and that they have taken into account the risks involved, however small they might be.
Steven: Right, and you know one of the things that comes up sometimes is people will feel compelled to stick to form, right? It's a “yes” or a “no” check box, and you're not quite sure. Our recommendation, in general, is well then don't write - don't check yes or no, write a statement to explain what it is that you're thinking. It's much clearer, and it much more represents the fact that you're thinking about it, that you're making a judgment call.
Yolanda: Yeah, qualify those statements, and really it's not the yes or the no or the black and the white. It's the approach and the framework that are important, and they really apply across the board.
Steven: Your due diligence is key here, whether it's a broken small toe or a third concussion, right? The stakes may be different, but the decisional process…
Yolanda: The approach, the framework is really what's at the heart of this.
Steven: They're the same. Establishing a sound practice pattern that you repeat over and over again is truly the way to promote safe, reliable care.
Yolanda: Let's take for example an athlete trying out for a team. They might want to portray the illusion of health and are not too keen on wearing the brace, and they may want to go back to play before they're actually ready. Well, it is their choice, but if something were to happen, you'd want to be able to demonstrate that your recommendations included a discussion of the risks of not wearing the brace or going back to play too soon.
Steven: Is that your documentation tip?
Yolanda: That is indeed my documentation tip. I guess that was. Steven, it's your turn. How about a communication tip for us.
Steven: Well, I would say that everyone has a voice, as we've mentioned. The patient for sure has a voice, but sometimes even the coach, the employer, the teacher, the insurance company, and while you can listen to everyone, your duty is to your patient. Be mindful of the tone you use when you make your recommendation, especially when it doesn't align with what your patient wants. Those are very emotional decisions, and those are key moments in the doctor-patient relationship that can make it or break it.
Yolanda: That's such as good tip, Steven, because in the majority of our College complaints, there's at least an element of dissatisfaction with communication or a frank communication breakdown, and these scenarios that we've described do put stress on the doctor-patient relationship.
Steven: Well, that's it. I think that's all the time we have, so I do hope this podcast was helpful.
Yolanda: My goodness. Time flies when we get going, doesn’t it?
Steven: It certainly does. Thank you very much for joining me today, Yolanda.
Yolanda: Thanks for listening today. It was a pleasure, Steven.
Steven: Thank you for joining us on our podcast. If you have any suggestions or ideas, please remember that you can send them along at podcasts@cmpa.org.
Yolanda: Remember, when you change the way you look at things…
Steven:...the things you look at change.
Yolanda: Good-bye, everyone.
Steven: Have a good day.
Announcer: These learning materials are for general educational purposes only and are not intended to provide professional medical or legal advice, nor to constitute a “standard of care” for Canadian healthcare providers.