Mastering Difficult Conversation as a Physical Therapist

Often times, physical therapists are put into a place where we need to have a conversation with family explaining their loved ones cannot go home, can’t live alone, won’t be able to drive, can’t feed themselves, or their impulsivity or memory causes harm to their independence.   Sounds so familiar, isn’t it? Being able to have a difficult conversation is a key part of the physical therapist’s routine.  We may have to have this kind of conversation once a week or month or more often!!

difficult conversation

Yes, these are a very difficult, emotional yet crucial conversation that we, as clinicians, need to have with the family of our patients, and it is no FUN.  After all, independence is what they have got, mainly if they are old aged. To them, they are very safe and things just happen!! It does not mean they have to lose their house (that they have built by themselves after a wedding and move in with family), or it’s time to say goodbye to their favorite car!! I have been in these kinds of situations several times. One thing I learned is that this conversation is never easy, but when you state the facts, point out the exact scenarios, it can go a lot smoother! Here are some tips that I have learned from my experience in my practice.

Know your patient before the Conversation 

This is the MOST important thing. You need to know what is important to your patient in his/her life, what is the purpose that he/she wants to get better. Majority of times, they will tell you during your evaluation or during one of your treatment sessions. “I want to go home…” yes, but go home and do what? Maybe it’s cooking, it’s gardening, it’s being able to attend that social group of bingo again or be able to sit on bar stool, etc… This is their goal why they are working hard with you in rehabilitation.

When you work with your patient on daily basis, they need to know that you both are in the same team and the kind of exercises you are prescribing/providing is for them to be able to achieve “that goal”. We should educate our patients about individual effects of all specific exercise like it works on what part of his/her body and how that will help them to achieve their goal. I am not asking to educate the patient about muscle’s name or blood supply or any of those details but just general information like you use your quads or thighs and glutes or butt muscles for sit to stand.  Exercises like mini squats or wall squats help strengthen those muscles!!

Develop a rapport with the family, and IDT team 

This is mainly for inpatient rehabilitation. Whenever my patient achieves a goal or starts doing something for the first time, I pick up the phone and call their wife, daughter, son or their primary contact. They always appreciate it. This serves two purposes. Number one, this is happy news and they want to know that their loved ones are doing better and the second one is to develop a rapport with them.  I also have experiences that when I call them, the family members start feeling comfortable with me and they share some of the important information that can help in discharge planning or know your patient more. If a therapist and family members are on the same page, then the carryover of home exercise program is high. Developing rapport will help, particularly, when you need to have those really difficult yet crucial conversations.

LISTEN to the other side during the Conversation 

This can be a little tricky. Having the patience to listen to your patient and family members is sometimes time taking. You may feel it’s not going anywhere. This is where they will provide you with all the information. The family will also inform you of the reality of why it is the way it is. Now, as a clinician, you are not going to change some one’s family dynamic or life story. But you can educate, share your ideas, experiences and share the benefits of your advice.

Sometimes, especially when we are having these conversations, the stakes are so high that the conversation becomes more of argumentative and blaming in nature. The family wants to hear something from you that you as a clinician are not recommending.  This is the time, you need to remember, it’s not a win or loses situation, it’s not that you did or did not do something, but the family or patient is having hard time processing.

Try to understand the other side during the Conversation

Take a step back mentally, think about the patient, remind yourself that this was the most important thing for them and you are telling them that they won’t be able to do such and such anymore, they are going to give you some resistance. It is OK. After you realized this, remind them again from all your treatment sessions, that what you and your patient have worked hard for, what they have achieved, and point out the things they did not do right or forget and that is why you are worried about their safety and you don’t recommend your patient to do that thing. Usually going through these steps and “walking” your patient and family step by step in this process works. They realize the situation and chances are that they will accept it!!

Explain and Educate during the Conversation 

You are a clinician, right? You thought physical therapist prescribes exercise, and develop a plan of care. That is what I thought as a new grade as well. But I learned that more than anything, I spent my time educating the patient, family, IDT members, sometimes my co-workers. I am not a professional teacher but I am constantly educating and explaining – it might be about the importance of body mechanics, exercise, lifestyle, energy conservation, muscle work in different daily activities, reasons of muscle soreness, pathology of illness or disease, etiology of disease, compensatory movements and so on. sometimes, you are educating regarding the same thing again and again. But let me tell you, educating your patients and their families is very important. Although the carryover is less than 50% but they understand that you know your stuff. This is very important to gain their trust. 

Admit your mistake if any

When you are having this difficult conversation, and you just find out some information that you did not know about then say so. If you did not concentrate on some particular activities say so. Be honest with your patient and family and to our self.

FOLLOW UP after the Conversation 

If you tell your patient or family members that you will let them know about something, please do so. If you told them you will follow-up in a week, mark it on your calendar and do a follow-up. This will give you a lot of credibilities and your patient will trust you on your words.

Have FUN

Have fun in what you do. SMILE. Greet your patient with respect and happiness on a daily basis during your session, even if they are one of that difficult, grumpy patient. You want to set your standards high. After all, you are a clinician, you are a physical therapist. You need to love what you are doing, have a passion for your work. That definitely transpired. Your patients surely feel your passion, your love towards your work or vice versa. This will make them respect you in return. Please visit my article on how to succeed as a PT in a sub-acute care facility for more information. 


In the end, I am going to stress that every patient and family is unique. We always have to keep that in mind while having this conversation. This is a general post and can help you strategize your approach. I am certain that having a patient-centered approach, excellent physical therapy treatment and a bit of strategy the difficult conversation can be a successful one!


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NOTE: The contents of this blog are for informational purposes only and are not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you have regarding a medical condition, and before undertaking any diet, dietary supplement, exercise, or other health program.
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