Elise Cantu (00:19)
Hey, Onco PT and welcome back to this episode of the Onco PT podcast. In this week’s episode, we are going to talk about something that

Hey Onco PT and welcome back to this episode of the Onco PT podcast. In oncology physical therapy, we like to do things. You are a go-getter. You like to make a plan and you like to put the plan into action. And that’s what I love about you. And it’s also why it can be really hard when the best course of action is to not actually do the plan. When it’s actually most appropriate to with

hold treatment or pause treatment when working with a person who has cancer, for example. And I’m not talking about modifying or adjusting or reducing the intensity of your interventions. I’m talking about we need to pause for a few different reasons. We’ll talk about them later in this podcast episode, but actually deciding not to move forward with treatment that day.

And for a lot of early career oncology physical therapists, that decision feels like a failure. ⁓ that feels so heavy. And it’s not because you don’t understand safety, right? In fact, if you are choosing to withhold treatment, it’s because you are acutely aware of the safety ramifications that might be at play.

But this can still be really hard, even though you know this was a good decision because your identity as a physical therapist, as a oncology physical therapist, as an oncopathy, as a healer at your core is tied to helping people. And helping feels very different and sometimes the opposite of holding treatment. And that’s what we’re going to unpack today in this episode.

Now, I think this comes from a few different reasons and why it can be really conflicting and internal conflict that we feel as oncology physical therapists, even though we know that it might be the most appropriate thing for this person. And I think the first thing that we need to acknowledge right off the bat is this productivity culture that we have. Now, maybe…

This is not your experience. And genuinely, I’m extremely jealous because that has not been my experience ⁓ in my early days as an oncopete. But we as Americans, especially as American healthcare workers, we have such an obsession around productivity. And as you can tell, I really, really hate this concept because productivity, I think is a

mask that sometimes corporations hide behind to get away with not really caring for people appropriately. ⁓ And before I lose myself in this very, very strongly held rant that I will not go on, not go down in today’s podcast episode, you know, a lot of your performance sometimes and your income and your ability to stay at a job sometimes

comes down to are you meeting the productivity standards of your institution? And when you don’t treat a person, when you withhold treatment from a person because they are unsafe to or they are not appropriate to participate in rehab that day, that ultimately can come back and reflect on you more than it can your superior clinical judgment skills.

And I hope, I genuinely hope from the bottom of my heart, you are in an institution that recognizes the medical, you know, dynamicness and the instability that this patient population can sometimes experience. I also know that that’s not the case for everybody. And I’m really, really sorry about that. But this, think is part of the issue that we are so consumed by our obsession with, you know, I need to have a 90 % show rate or whatever. And if I don’t that

looks back, you know, that looks bad on me, or I need to meet, you know, if I’m working in an outpatient, I need to have an average of 4.25 units per patient encounter that I have every single day, blah, blah, blah, blah, whatever, right? And this, this absolutely contributes. We could not have this conversation without acknowledging how significantly productivity plays into all of this.

That’s not the only contributor to all of this, but we would not be having a real discussion around this if we didn’t really lead off this conversation with this productivity baloney that really drives so much of what American healthcare really looks like. And it’s a hot mess. You know this, you don’t need me to tell you this. But.

I also want to talk about some other reasons why we can feel very conflicted. We can feel like we sometimes made the wrong decision by withholding treatment from a person who was not appropriate for it. And that also comes down to back to our identity of a healer, right? Again, you’re a physical therapist, you’re a healer at your core. And we feel a lot of times, or you may have encountered this attitude of if you’re not progressing them, are you even helping them?

Right, because in again, I’m not trying to bash entirely on orthopedic physical therapy, but that was the basis of a lot of my physical therapy education. I think that’s, know, there’s a reason for it, right? That’s a lot of what physical therapy is. But in orthopedics, there’s very much a very linear progression. You know, if a person tears their ACL and they go through ACL surgery,

There is a post-surgical protocol of by this date, the person should have this kind of range of motion. It’s very linear. This very linear progression and upward movement is very expected. And it’s like, okay, you know, I know what I’m supposed to be doing. I’m always supposed to be getting better, always better, always better, always better. That is not always the reality in oncology physical therapy.

One, the person may have fluctuations in their physiologic capacity because they’re going through chemotherapy. And some days they feel like junk and some days they feel like not so much junk. And so that can differ how much you’re able to do with that person. There may be instances where there’s other medical kind of circumstances at play. ⁓ know, thinking about someone who has advanced cancer, know, progression of disease.

that changes their physiologic capacity to participate and their physiologic capacity to potentially improve in some of these PT goals that we might have set for ourselves. There are situations where progression is not necessarily an indication of how much you are helping this person. But again, we tend to equate progression with

More progression means more helping them. The more I progress a person, the more I’m helping them get better, right? And that’s not always equivalent. Those don’t always equate to each other. Now, it can also, this kind of icky feeling from withholding treatment from someone, is sometimes the discomfort of sending them home. Or, I’ll give another example here later in this podcast episode.

of feeling like you’re inconveniencing someone by sending them to the emergency department, for example. Sometimes that is the most appropriate decision you can make for a person. And yeah, you’re not going to bill for any units that day because you didn’t get through your three sets of 10 of TheraBand external rotations or whatever, but that might be the most appropriate decision that you could have made for that person. And that was the decision that needed to be made.

There’s sometimes also a fear that you might have deep within yourself of fear of looking passive or even weak by not treating a patient or that you’re not competent or that you don’t know what you’re doing. Fear of being judged by your fellow rehab team or your medical team.

I’m gonna pause myself because I feel like I’m gonna get really worked up on that one.

But sometimes, again, withholding that treatment might be the most appropriate thing for that person. And frankly, to hell with what other people think, because you are the person that has to go home and sleep with yourself at night and live with your decisions. And if other professionals, if other people don’t understand that you are making the most appropriate decision for a patient, again, to hell with them, because you have to be the one who is okay with yourself at the end of the day.

Holding treatment for you know, whatever the reason and for whatever your hesitations may be around it holding treatment Challenges your identity as a fixer, right? You’re a healer you help people get better you fix things and these are kind of at odds with some with each other sometimes and that’s why withholding treatment can feel heavier than what it might appear on paper one of the biggest

developmental shifts in your oncology practice is realizing that restraint might actually be active care. Not might be, it can be active care. Holding isn’t necessarily the absence of intervention, it is a decision. And as you know, making a decision as an oncology physical therapist requires reasoning.

Early on, when you are a ⁓ newer onco PT, and again, this plays into the reasons we talked about earlier, productivity and also some of the others, you measure your value as an onco PT by how much you get done in a session. I know for me, when I first started practicing, it was all about how many repetitions of exercise can I possibly fit into one session?

And that often meant I wasn’t being really. ⁓

Consider I wasn’t being ⁓ intentional about really pushing my patients in intensity because I was trying to do more repetitions, for example. And so again, early on in your practice, you’re much more concerned with how much can I actually get done in a session? With time, with reflection, with introspection, you later measure your value as an onco PT by the quality of your judgment.

So altogether, early on, you measure your value by how much you get done in a session. Later, you measure your value as an OncoPT by the quality of your clinical judgment. This is a quantity versus quality conversation here. And we are always going to prioritize here on the OncoPT quality over quantity. So couple examples of this.

So there might be some very like medically appropriate situations in which you need to withhold treatment. For example, I worked with a gentleman a few years ago who had advanced cancer and he came into the clinic one day and he looked visibly not okay. He looked like he was working way harder than he should have been walking from his car in the parking lot to our front door. And

He was out of breath and things just did not look right. And so I sat him down and I said, hold on, took his vitals. Vitals did not look good. Again, that combined with his presentation. I ended up calling the triage nurse. I was inside the cancer center at this time. They ended up calling the crash cart and then they transported him by ambulance to the emergency department where he was admitted to the hospital because he was having like major cardiac issues.

And that was a decision I could have totally said, you know what, like, ⁓ I really, really need to bill for four units of Therax that day or whatever. Like I really, really need to get this productivity in. But the clinical decision I made because I am trying to be the best oncology physical therapist I can, which was this doesn’t look right. This doesn’t look good. This person is not appropriate for treatment today. ⁓ We need

We need to stop. need to not work on this right now. So again, that’s a very obvious medical situation in which like, you know what? Things are not looking good. Like this is not a good situation. Medically, this person needs to be managed. But what about maybe something with a little more nuance? So I worked with a person previously. ⁓ She was a woman in her, I think, 60s, roundabouts.

And I had been working with her for a while and initially we were making great progress with her impairment. was getting stronger. Her balance was getting better, like all the good things. And then after a while she started to plateau. And so I’m kind of thinking through like, Hmm, okay, what’s happening? You know, trying to just think about like, okay, what am I doing as a physical therapist where we’re not making progress? And then

she started to actually decline physiologically. So her strength decreased, her weakness was more apparent, her balance started getting really, really squirrely again. And eventually after enough time of seeing this trend of things are not going in the right direction and I’ve done all that I can in physical therapy, I need to have a conversation with this patient, eventually,

It came out that this person was kind of self-starving. ⁓ They were following a really, really restrictive diet that was limiting the nutrients that their body was getting to the point that they did not have the physiologic capacity to even participate in physical therapy. I was doing more harm in physical therapy than what the benefit was of her actually attending physical therapy because her body had absolutely no gas to give.

in these exercises. And it was really, really challenging to have this ongoing conversation with this patient of we are doing more harm than good until your body gets the nutrition that it needs. you know, we were really fortunate. We had a registered dietitian in house, like we were working together. And unfortunately, you know, again, there’s a lot of situations, there’s a lot of circumstances. I’m not going to share her on the podcast because that’s private information.

but this patient was adamant that she was not going to change her diet and was not going to basically increase the number of nutrients that she was getting into herself. And I made the decision to discontinue physical therapy. And it felt like a failure. It really did because I felt like my job was to help this person get stronger, get better with their balance, to be safer around the home so that she can take her trash can out

of her little cottage to the dumpster, cetera. I could not outdo what she was doing to her own body. And it was really, really challenging and it was really hard to sit with. know, last episode we talked about sitting in the uncertainty and the discomfort. This was absolutely sitting in the discomfort of knowing I could not do anything.

that was going to actually help this person until they could stop and take care of themselves. And sometimes that is a situation that you might encounter in oncology physical therapy. It felt like withholding treatment in that way. Like I hadn’t…

I felt like a failure. It felt like I was kind of not being, I felt like I wasn’t being a good physical therapist in that moment. Despite now, you know, reflecting, I did everything I absolutely could have with as much compassion as possible, with as much multidisciplinary, you know, collaboration as we could. This, like, this was a very serious situation.

And it made me, you know, at the time really questioned if I was being a good oncology physical therapist. I was practicing, you know, working towards becoming a specialist. And over time with reflection, I realized that the opposite is actually true. Holding that treatment very appropriately for that second patient that I’ve mentioned required more confidence in my clinical decision-making than pushing through.

And I tried pushing through y’all. Like I tried everything to get through to this person that I knew how to, but there came a point where I realized I cannot do anything more. And you have probably encountered a very similar situation, maybe not nutritionally, right? Like that is the very specific circumstances of that second patient ⁓ scenario we’re talking about here. But you have encountered that before for whatever reason where you

know in your heart of hearts, your, bottom of your soul, that withholding treatment is the most appropriate, is the best decision that you can make for that person in that day. And maybe it’s not a forever thing, right? Maybe it’s a, you know, today is just not the day and that’s okay, but it takes a tremendous amount of skill and confidence to make that decision. Part of why, and again, this is, this is

a concept that I have come to appreciate and understand the longer that I have practiced. And I don’t want you to walk away from this episode thinking like, ⁓ I just have to keep practicing and I have to practice for tons and tons of years. And eventually I’ll just get better at this. No, like there was a lot of struggling I did on my own to get to this point. And that’s why I’m sharing this information so that you can feel secure in making those sometimes really difficult decisions.

but that you know are ultimately for the best of your patient. And part of why this kind of decision making can feel so heavy is that a lot of times you’re making that decision on your own. You are the one who is in the room with the patient, maybe by yourself, maybe you’re the only oncology physical therapist who is sitting with those hard decisions and ultimately arriving at this is what needs to be done in this moment. And you may not often hear how others

are really navigating this kind of situation. And this is way more common than it is not. And it doesn’t seem like it because we don’t talk about enough. We don’t talk about this in these very cancer rehab spaces unless we very intentionally navigate it. And so when we don’t talk about these out loud, you don’t get to calibrate your thresholds of, you know what, this is actually the point at which I would say, no, I’m not gonna do treatment. Or, you know what?

I actually might change my kind of internal thermometer of I would maybe treat that person next time with this particular situation, but you don’t get to that point. You don’t arrive at that again, that that shift that kind of up leveling in your thinking until we do it together until we talk about it. And when you’re isolated in this way, every pause and every moment of uncertainty feels magnified.

It feels even bigger, even badder, even worse than what it probably actually is because you are within the echo chamber of your own brain. And this is one of the exact reasons that we created the Cancer Rehab Community Conference because these conversations that we have together as cancer rehab professionals are really what change how you practice and not just the exercises that you prescribe.

You can get that from the research. And again, research is very necessary. But what we really need, what you really need right now is that collaboration and that common conversation to get you to that next point where you feel more comfortable with making these kinds of decisions, like withholding treatment, much, much sooner than struggling through it on your own for years, frankly, like I did. I wouldn’t wish that on anybody because it was a hard and lonely road.

If you have withheld treatment recently and have felt unsettled or uncertain about it, it does not mean that you’re weak. It does not mean that you are a failure of an oncology physical therapist. It means that you are stepping into a more complex level of clinical reasoning. The goal in cancer rehab and in oncopathy is not to treat at all costs.

The goal is to intervene when is appropriate, when the intervention adds value. And sometimes that means taking a pause and knowing that intervention is not going to add value in this particular situation. Now in next week’s episode, we are actually going to talk about the opposite tension that you can experience in oncology physical therapy.

which is where you can be too cautious. When caution bleeds into the realm of being overly conservative with your interventions, with your clinical decision-making. And I know it seems like we’re really swinging from one end of the spectrum to the other, but if there’s something that I know about early career oncology physical therapists, you probably do that swinging back and forth on a daily basis, if not within the same session.

So we’re going to talk about it and we’re going to reconcile these very, different ends of the spectrum and bring it together on ultimately how do you feel more confident in your clinical decision-making. But until that episode releases and until next time, this is Elise with the Onco PT. And remember, you are exactly the physical therapist that your patients with cancer need. So let’s get to work.