Content

Content

close
Browse Content
Narrative Reflections - Spring 2024
At Capacity: How Physical Therapists Will Gain More by Doing Less
Narrative Reflections - Spring 2024

At Capacity: How Physical Therapists Will Gain More by Doing Less

Contents
Introduction
AI and Humanism in Patient Care
My History as Guidance
AI’s Potential for Cultivating Humanistic Care
About the Author(s)
Share this:

At Capacity: How Physical Therapists Will Gain More by Doing Less

By Hannah Sy, PT, DPT

Download the article (pdf)

Congratulations to recent graduate of Northwestern University’s Doctor of Physical Therapy Program Hannah Sy, the winner of the 2023-2024 Student Essay Contest, co-sponsored by the American Counsel of Academic Physical Therapy (ACAPT) and the Journal of Humanities in Rehabilitation (JHR). The seventh in an annual series, this national contest offers a creative opportunity to ignite critical reflection in physical therapy students across the nation to support holistic approaches to patient care. This year’s essay prompt was:  

Advances in AI technology are poised to transform the landscape of rehabilitation, raising intriguing questions about its impact on humanism in the field.

How do you envision the integration of AI technology in rehabilitation impacting the essence of humanism in patient care? Discuss potential benefits and challenges in maintaining a compassionate, patient-centered approach while utilizing AI-driven techniques. Reflect on the role of empathy, personal connection, and tailored treatment plans in humanizing the rehabilitation process amidst increasing reliance on technological solutions. Draw insights from contemporary viewpoints on writing effective PT application essays, emphasizing the importance of weaving personal experiences and stories into your response to convey your understanding of AI’s potential impact on the humanistic dimension of rehabilitation.

Note:  This essay prompt was generated by ChatGPT when given the prompt: “Write a physical therapy student essay prompt on the following topic – how will AI technology impact humanism in rehabilitation?”   OpenAI. (2023) ChatGPT Aug 18 version. [Large language model] https://chat.openai.com/chat

We have chosen the topic of artificial intelligence and machine learning for our 2023-2024 essay contest prompt in recognition of the tremendous opportunities this technology offers in our world, as well as the profound societal implications. It is precisely in this space of creative tension that the skills we gain from the humanities provide critical insights to help us interrogate, embrace, and ultimately shape what this revolutionary technology is asking of us as humans.

Introduction

If I asked Katniss Everdeen in The Hunger Games what her mission in life is, I imagine I would receive an arrow straight to the heart. Without food, while fending for her life, her entire faculty is geared solely toward survival, and life mission statements would most understandably not be on her priority list. On the other hand, I imagine Princess Rapunzel in Tangled would have an answer in a heartbeat. She leaves the comfort of her tower in search of belonging and greater meaning to her life, made possible because all her basic needs are met.

With each need met, assumedly, one’s capacity to meaningfully engage with themselves and the world around them increases. This phenomenon of having the ability to reallocate one’s mental, emotional, and intellectual capacity depending on circumstance, parallels the philosophy of Maslow’s hierarchy of needs and offers an imaginative lens to envision the potential impacts of artificial intelligence (AI) in rehabilitation.

AI and Humanism in Patient Care

What if we imagined the impact of AI on the essence of humanism in patient care through Maslow’s philosophy? In a physical therapy rendition of Maslow’s pyramid, I believe humanistic patient-centered care would be the pinnacle. Humanistic care sensitive to a patient’s values, cultural background, and preferences is essential for quality patient care.

Imagining the potential impact of AI on humanistic patient care would not be feasible without reflecting on the current state of humanism in patient care. Prior to physical therapy school, I was a rehabilitation technician in a high-volume outpatient orthopedic clinic. Repeated emotional stresses due to managing a high patient load, resulting in burnout was so prevalent that therapists tried to convince me not to pursue the profession. As a third-year student physical therapist I have navigated numerous health systems in various clinical settings. The aggregate of my clinical experiences informs my perspective that the essence of humanism in patient care has long been and continues to be threatened by productivity standards and documentation load. The intricate and systemic interplay of reimbursement rates and health system business models impacts the lived experience of physical therapists, and most often shows up in the form of burnout.

The prevalence of physical therapist burnout is good reason to consider that perhaps the essence of humanism in patient care is already at stake, and AI can serve to increase the humanistic capacity of clinicians. The potential for AI is boundless in rehabilitation, and even the most pedestrian of applications would offer benefit to a clinician’s humanistic patient care. Consider that if AI could generate an evaluation or treatment note based on objective inputs that I provide, my documentation burden would decrease. In turn, my time, attention, and mental capacity that would have been allocated toward documentation would be newly available to be directed toward being present with patients.

My History as Guidance

During the initial weeks of my long-term clinical rotation in acute care oncology, I found that I did not have the mental bandwidth to fully engage with patients on a personal and emotional level. Managing lines and tubes took my full attention, so I had trouble simultaneously talking with the patient to take a subjective exam. I did not attempt to get to know patients during sessions because observation of their gait pattern and guarding appropriately took the entirety of my focus. I failed to acknowledge family members in the room because I was intent on accomplishing everything on my mental checklist. As tasks became second nature with each week, my ability to engage thoughtfully increased. I became available to offer a listening ear without attempting to rush out of a session when patients wanted to verbalize their emotions. My ability to read the room increased, resulting in the ability to gauge if there was a witticism I could offer to make a patient smile. My needs of mastering psychomotor tasks, safety, and clinical judgment had to be met before I gained the capacity to be fully present and empathetic.

AI’s Potential for Cultivating Humanistic Care

Using AI-driven techniques in rehabilitation does not challenge humanism of patient care but rather the skill of patient care. My education equips me with the skill and knowledge to develop personalized treatment plans. With its processing power, AI can also develop tailored treatment plans for each patient when provided with the necessary data. Computer intelligence’s ability to perform an aspect of my role as a Doctor of Physical Therapy may render my skills redundant, but it would not render me less human.

The advantage of AI in patient care is its ability to solve complex problems with its capacity to process copious amounts of data. Patients, however, are more than data points. They are people with unique personalities, dreams, and stories. Thoughtfully engaging with these aspects of who patients are requires human connection and makes their care humanistic. Artificial intelligence as it currently is, has no capacity to develop relationships. So long as this is true, AI can only address the levels underneath the pinnacle of a physical therapist’s hierarchy of needs, and thus increase their capacity for humanistic patient care.

Statement regarding use of AI in authoring this essay:

Since this piece is subject to human review, I chose to forgo the use of AI out of the belief that my writerly voice wields more effective storytelling power to express my personal narrative.

Footnotes

References


This work is licensed under a Creative Commons Attribution 4.0 International License.

About the Author(s)

At Capacity: How Physical Therapists Will Gain More by Doing Less

Contents
Introduction
AI and Humanism in Patient Care
My History as Guidance
AI’s Potential for Cultivating Humanistic Care
About the Author(s)
Share this:

At Capacity: How Physical Therapists Will Gain More by Doing Less

By Hannah Sy, PT, DPT

Download the article (pdf)

Congratulations to recent graduate of Northwestern University’s Doctor of Physical Therapy Program Hannah Sy, the winner of the 2023-2024 Student Essay Contest, co-sponsored by the American Counsel of Academic Physical Therapy (ACAPT) and the Journal of Humanities in Rehabilitation (JHR). The seventh in an annual series, this national contest offers a creative opportunity to ignite critical reflection in physical therapy students across the nation to support holistic approaches to patient care. This year’s essay prompt was:  

Advances in AI technology are poised to transform the landscape of rehabilitation, raising intriguing questions about its impact on humanism in the field.

How do you envision the integration of AI technology in rehabilitation impacting the essence of humanism in patient care? Discuss potential benefits and challenges in maintaining a compassionate, patient-centered approach while utilizing AI-driven techniques. Reflect on the role of empathy, personal connection, and tailored treatment plans in humanizing the rehabilitation process amidst increasing reliance on technological solutions. Draw insights from contemporary viewpoints on writing effective PT application essays, emphasizing the importance of weaving personal experiences and stories into your response to convey your understanding of AI’s potential impact on the humanistic dimension of rehabilitation.

Note:  This essay prompt was generated by ChatGPT when given the prompt: “Write a physical therapy student essay prompt on the following topic – how will AI technology impact humanism in rehabilitation?”   OpenAI. (2023) ChatGPT Aug 18 version. [Large language model] https://chat.openai.com/chat

We have chosen the topic of artificial intelligence and machine learning for our 2023-2024 essay contest prompt in recognition of the tremendous opportunities this technology offers in our world, as well as the profound societal implications. It is precisely in this space of creative tension that the skills we gain from the humanities provide critical insights to help us interrogate, embrace, and ultimately shape what this revolutionary technology is asking of us as humans.

Introduction

If I asked Katniss Everdeen in The Hunger Games what her mission in life is, I imagine I would receive an arrow straight to the heart. Without food, while fending for her life, her entire faculty is geared solely toward survival, and life mission statements would most understandably not be on her priority list. On the other hand, I imagine Princess Rapunzel in Tangled would have an answer in a heartbeat. She leaves the comfort of her tower in search of belonging and greater meaning to her life, made possible because all her basic needs are met.

With each need met, assumedly, one’s capacity to meaningfully engage with themselves and the world around them increases. This phenomenon of having the ability to reallocate one’s mental, emotional, and intellectual capacity depending on circumstance, parallels the philosophy of Maslow’s hierarchy of needs and offers an imaginative lens to envision the potential impacts of artificial intelligence (AI) in rehabilitation.

AI and Humanism in Patient Care

What if we imagined the impact of AI on the essence of humanism in patient care through Maslow’s philosophy? In a physical therapy rendition of Maslow’s pyramid, I believe humanistic patient-centered care would be the pinnacle. Humanistic care sensitive to a patient’s values, cultural background, and preferences is essential for quality patient care.

Imagining the potential impact of AI on humanistic patient care would not be feasible without reflecting on the current state of humanism in patient care. Prior to physical therapy school, I was a rehabilitation technician in a high-volume outpatient orthopedic clinic. Repeated emotional stresses due to managing a high patient load, resulting in burnout was so prevalent that therapists tried to convince me not to pursue the profession. As a third-year student physical therapist I have navigated numerous health systems in various clinical settings. The aggregate of my clinical experiences informs my perspective that the essence of humanism in patient care has long been and continues to be threatened by productivity standards and documentation load. The intricate and systemic interplay of reimbursement rates and health system business models impacts the lived experience of physical therapists, and most often shows up in the form of burnout.

The prevalence of physical therapist burnout is good reason to consider that perhaps the essence of humanism in patient care is already at stake, and AI can serve to increase the humanistic capacity of clinicians. The potential for AI is boundless in rehabilitation, and even the most pedestrian of applications would offer benefit to a clinician’s humanistic patient care. Consider that if AI could generate an evaluation or treatment note based on objective inputs that I provide, my documentation burden would decrease. In turn, my time, attention, and mental capacity that would have been allocated toward documentation would be newly available to be directed toward being present with patients.

My History as Guidance

During the initial weeks of my long-term clinical rotation in acute care oncology, I found that I did not have the mental bandwidth to fully engage with patients on a personal and emotional level. Managing lines and tubes took my full attention, so I had trouble simultaneously talking with the patient to take a subjective exam. I did not attempt to get to know patients during sessions because observation of their gait pattern and guarding appropriately took the entirety of my focus. I failed to acknowledge family members in the room because I was intent on accomplishing everything on my mental checklist. As tasks became second nature with each week, my ability to engage thoughtfully increased. I became available to offer a listening ear without attempting to rush out of a session when patients wanted to verbalize their emotions. My ability to read the room increased, resulting in the ability to gauge if there was a witticism I could offer to make a patient smile. My needs of mastering psychomotor tasks, safety, and clinical judgment had to be met before I gained the capacity to be fully present and empathetic.

AI’s Potential for Cultivating Humanistic Care

Using AI-driven techniques in rehabilitation does not challenge humanism of patient care but rather the skill of patient care. My education equips me with the skill and knowledge to develop personalized treatment plans. With its processing power, AI can also develop tailored treatment plans for each patient when provided with the necessary data. Computer intelligence’s ability to perform an aspect of my role as a Doctor of Physical Therapy may render my skills redundant, but it would not render me less human.

The advantage of AI in patient care is its ability to solve complex problems with its capacity to process copious amounts of data. Patients, however, are more than data points. They are people with unique personalities, dreams, and stories. Thoughtfully engaging with these aspects of who patients are requires human connection and makes their care humanistic. Artificial intelligence as it currently is, has no capacity to develop relationships. So long as this is true, AI can only address the levels underneath the pinnacle of a physical therapist’s hierarchy of needs, and thus increase their capacity for humanistic patient care.

Statement regarding use of AI in authoring this essay:

Since this piece is subject to human review, I chose to forgo the use of AI out of the belief that my writerly voice wields more effective storytelling power to express my personal narrative.

Footnotes

References


This work is licensed under a Creative Commons Attribution 4.0 International License.

About the Author(s)

Hannah Sy, PT, DPT

Hannah Sy, PT, DPT is a recent graduate from Northwestern University’s Doctor of Physical Therapy Program. She graduated from Azusa Pacific University with a Bachelor of Arts in Allied Health, and her liberal arts undergraduate education informs her curiosity and love for pursuing knowledge in both the humanities and sciences. She is the recipient of the Advanced Healthcare Practice Scholarship Program Grant from the California Department of Healthcare Access and Information and the Edna Foster Wright Scholarship from Northwestern University. Her clinical interests include cancer rehabilitation, and professional interests include leadership development and creating cultures of value and belonging. In her free time, she enjoys reading, longboarding, making pottery, crocheting, and conversing over a cup of coffee.

 

CONTINUE READING...
NO COMMENT

At Capacity: How Physical Therapists Will Gain More by Doing Less

Contents
Strategic Swearing
Reflections on Strategic Swearing
Where Do We Go From Here?
About the Author(s)
Share this:

Can Swearing Be Professional and Patient-Centered?

By Nicholas B. Washmuth, DPT, Adam Meakins, PT, Garrett Trummer, DPT, and Richard Stephens, PhD

Download the article (pdf)

Strategic Swearing

Introduction by Nicholas B. Washmuth

As a faculty member in a physical therapist education program, I was introduced to the positive effects of swearing in 2019 when a student sent me a manuscript by Stephens et al,1 “Effect of Swearing on Strength and Power Performance,” discovering that swearing can enhance physical performance. I received this article somewhat humorously, as the student was jokingly suggesting that swearing deserves attention in the physical therapy setting. Although my attention was drawn to this manuscript amusingly, it had a profound impact on my research direction, raising more questions than it answered. A quick literature search to explore this newfound curiosity revealed that swearing is associated with not only improvements in physical performance, but a decrease in pain perception,2–6 heightened humor,7 conveying credibility,8 enhancing solidarity and rapport building,7,9–11 and improvements in memory and recall.12,13

It became evident that swearing is associated with positive physiological, psychological, and social effects that other forms of language could not replicate. For example, swearing has been found to increase pain threshold,3–5 increase pain tolerance,2–6 and even decrease social pain6 or the feeling of suffering brought on when social connections are lost or threatened. It was originally proposed that the mechanism by which swearing produces these hypoalgesic effects is an increase in sympathetic activation.2,3 However, other studies have found a lack of sympathetic activation even when swearing produced a decrease in pain perception.4,5 Although swearing possesses a unique power, it is currently unknown from where swearing gets its power. It has been hypothesized that positive associations between swearing and physiological, psychological, and social effects are mediated by emotion, humor, distraction, aggression, state disinhibition, psychological flow, risky behavior, self-confidence, and sympathetic activation.2–5,14,15 It is plausible that there is a combination of mechanisms behind swearing’s power, or that the mechanisms differ depending on the contexts of the situation. My research subsequently shifted toward understanding when, how, and if swearing could be strategically employed to enhance patient outcomes.

There is little discussion or research on the possibility that swearing may actually be considered professional and patient-centered when used in the appropriate context: with the right patient, at the right time, and for the right reason. In workplace settings, the use of the word “fuck” has been correlated with improved solidarity among co-workers.9 In the classroom, professor swearing is rated as appropriate when it is directed at course content to emphasize a concept.16 The context of every patient-physical therapist interaction is unique, and the appropriateness and effectiveness of certain behaviors will vary from clinic to clinic and from physical therapist to physical therapist.

The prevailing belief is that swearing by a physical therapist is inherently negative; however, swearing may be useful and perceived as appropriate given particular contextual factors. Anecdotally, physical therapists use swearing in certain situations. One example is presented below as a case vignette, describing how swearing was used by a physical therapist with the intention of portraying professionalism and patient-centeredness.

Case Vignette

‘Phoebe’ is an independent, confident, and athletic Caucasian woman. At the age of 25, she had never experienced a significant injury or illness and was renowned for her dedication to fitness; it was an integral part of her identity. However, her life took a dramatic turn over the course of 6 months. Phoebe began to battle an issue that was not only growing increasingly severe but also remarkably difficult to talk about. It was an issue that made her feel vulnerable, exposed, and overwhelmed with fear and embarrassment. For months, she had been silently contending with stress incontinence.

Initially, Phoebe’s stress incontinence had been relatively mild, and she was able to manage it by making modifications to her exercise routine and relying on pads. Unfortunately, it worsened to a point where it became unpredictable and far more severe, limiting her ability to work out. This strain on her identity was particularly profound. After years of daily visits to the gym, Phoebe found herself missing entire weeks of exercise, and her stress incontinence showed no signs of improvement.

Summoning the courage to seek help, Phoebe consulted a 33-year-old Caucasian male physical therapist whose clinic is next to her gym and has a reputation for treating athletes and fitness enthusiasts. During this consultation, she confidently shared her unfiltered history of stress incontinence, her goal of returning to her fitness pursuits, and her overarching desire to reclaim her sense of self. After listening and processing Phoebe’s narrative, the physical therapist said “This must be fucking tough for you.” The physical therapist observed an initial silent pause and expressionless body language from Phoebe, which he interpreted as being shocked by his use of an expletive. The physical therapist then described a quick transformation from Phoebe observed by her warm smile, open posture, and relaxed demeanor, which was interpreted as being acknowledged, heard, and understood.  Encouraged by this positive response, the physical therapist occasionally utilized swearing as a tool to sustain this rapport and social connectedness throughout the episode of physical therapy care.

While her name and specific details have been altered here, Phoebe’s case is based on real events. Phoebe experienced a successful episode of physical therapy, achieving clinical outcomes that aligned with the expected prognosis of her health condition. Notably, Phoebe had a 100% arrival rate and routinely arrived early to her physical therapy appointments. Although it was challenging for the physical therapist to convey these changes qualitatively, there was a discernible positive shift observed in how Phoebe interacted with her physical therapist immediately after he swore. This prompts the question: If swearing is inherently negative, why were there no apparent adverse consequences? Furthermore, why did the physical therapist perceive an enhanced social connection with the patient after swearing, potentially influencing Phoebe’s arrival rate and the positive shift in interactions? In the absence of empirical evidence, this case serves as a catalyst for reflection on the strategic use of swearing by a physical therapist.

Reflections on Strategic Swearing

A candid reflection of the case described above reveals that Phoebe’s clinical outcomes aligned with the prognosis of her health condition, suggesting that swearing did not significantly impact the outcomes. However, it’s worth noting that the physical therapist involved in this case considered the use of swearing to be both indicated and professional. This reflective narrative has its limitations. Primarily, this reflection is subjective and is influenced by the authors’ perspectives, leading to potential biases in interpretation and reporting. Consequently, this case cannot be generalized to broader clinical scenarios. Despite these limitations, this reflection aims to present a clinical approach that does not yet have a body of evidence to guide decision making, and to offer a ‘proof of concept’ for an approach with potential efficacy.

Why did the physical therapist feel it was indicated and professional to swear with the patient?

Phoebe presented to physical therapy with strong emotions, including a disconnection from her identity. The physical therapist faced the challenge of demonstrating genuine empathy toward the emotional state of the patient. Swearing, by definition, involves using emotionally-charged language that may be taboo in a particular culture.7 In this context, the swearing used by the physical therapist served as a tool to convey their understanding of the patient’s emotional experience and to build a therapeutic alliance based on the shared comprehension of the patient’s feelings and goals.

Swearing is generally viewed by many as unprofessional. The American Physical Therapy Association’s Code of Ethics emphasizes the importance of respecting the inherent dignity and rights of all individuals and maintaining integrity in relationships with patients.17 This Code highlights physical therapists’ fundamental duty to empower, educate, and support their patients.17 However, no ethical code can comprehensively address every situation. For instance, the appropriateness of specific language used by a physical therapist may be perceived differently by different patients, potentially having either a positive or negative impact. It’s crucial to recognize that the words used by physical therapists have the potential to affect social, psychological, and biological factors,18 either strengthening or weakening the therapeutic alliance,19 and causing either healing or harm.18,20

In Phoebe’s case, swearing served as a strategy to adopt a patient-centered approach. Patient-centered care involves tailoring care to a specific patient’s values and preferences, with the ultimate goal of empowering the patient.21 For strategic swearing to be effective, physical therapists must carefully consider the context in which it occurs. Although Phoebe’s specific attitude toward swearing was not explicitly explored by the physical therapist, it was the contextual understanding of her emotional state that prompted the physical therapist to swear, thereby demonstrating a shared empathy for her strong desire to reclaim her identity. It is worth noting that disciplinary actions have been taken against medical providers for their use of swearing, but most of these instances involve swearing out of frustration or anger, rather than a means to foster positive social connections.22,23 Recent evidence has suggested that ‘clout’ words, or words used to evoke a sense of importance or impact, are perceived by patients as patient-centered.24 The swearing utilized by the physical therapist may be considered a form of clout language and, therefore, a strategy for patient-centeredness.

The authority to swear may be related to the power dynamics within the patient-provider hierarchical structure.25 Although the physical therapist in this case did not feel entitled to swear, citing its lesser appropriateness in formal environments,26 it is important to acknowledge the existing hierarchy between patients and providers. This hierarchy, often associated with power imbalances, makes it more likely for a doctor to swear at a nurse than a nurse to swear at a doctor.25 Additionally, certain cues from Phoebe, such as smiling after the physical therapist swore, may suggest that the she was ‘dancing to the physical therapist’s tune’—feeling forced to accept the swearing due to the power dynamics of the physical therapist-patient relationship. The physical therapist found that the emotional nature of the case, coupled with the intention of strengthening the social connection, justified and exemplified the professionalism of strategic swearing.

And what about patient swearing?

This article delineates a case in which a physical therapist employs swearing as a strategy for patient-centered communication. However, what about the swearing behaviors exhibited by patients? Patients who demonstrate behavior considered inappropriate by providers, such as using foul language, are often unfairly labeled as “difficult.”27 A proposed solution to managing such “difficult” patients involves allowing them to vent, or swear, uninterrupted in a private setting, as swearing is believed to have cathartic effects.27,28 Patient swearing may have utility in a physical therapy setting, beyond its cathartic potential. A recent case report details the formal integration of patient swearing into a physical therapy plan of care. In this case, the patient opted for the swearing strategy of vocally repeating “fuck” during the most painful and challenging interventions, aiming to improve physical performance and decrease pain.29 However, the outcomes of swearing, whether by a patient or a physical therapist, are highly dependent on the context in which they occur. The next section will explore some contextual factors that may influence the effects of swearing.

What evidence can help us make sense of the swearing and outcomes of this case?

Swearing has been a part of human language since its inception30 and is prevalent in society, with evidence suggesting 58% of the population swears “sometimes” or “often;”7 more than 70% of adults report frequently or occasionally hearing individuals swear in public;31 and 57% of workers swear in the workplace.32 This suggests that swearing is prevalent in public discourse and a common part of everyday speech, even in more formal settings. However, the utility of swearing in physical therapy remains under-explored.

The challenge of interpreting and applying the evidence around swearing is that the majority of research on swearing tends to be categorical and conducted in non-naturalistic settings, while overlooking context. However, it’s crucial to recognize that the context in which swearing takes place ultimately determines whether it has a positive or negative impact. The limitations of non-naturalistic research and the significance of contextual factors in determining the outcomes of swearing have been described by Stapleton,33 and are underscored by research from Rassin and van der Heijden.8 When simply asked whether using a swear word is a sign of credibility, deceit, or neither, people tend to view swearing as an indicator of deceit. However, in the context of testimonies provided by crime suspects and victims, testimonies containing swear words were perceived as more credible than those without.8 This demonstrates the crucial role that context plays in the perception of swearing. The physical therapist in this case swore as a means to convey empathy and acknowledge the patient’s hardships. Emphasizing feelings is a common motive for swearing; therefore, swearing may be a strategy to express the understanding of strong emotions.34,35

The outcomes of a physical therapist swearing may be influenced by other contextual factors such as age, gender, and race of both the patient and physical therapist. Notably, the patient in this case (Phoebe) belonged to Generation Z, while the physical therapist was a Millennial. These different generational backgrounds shape their expectations, and given the potential for swearing to cause offense, it could be seen as risky behavior. Younger generations tend to be more inclined to participate in risk-taking compared to older ones.36 Consequently, swearing by young adult physical therapists in the presence of young adult patients may be perceived differently than when used by or in the presence of older generations. Moreover, gender differences in the use of swear words indicate that males tend to use stronger language than females. Research has shown that males use the word “fuck” and its derivatives nearly twice as frequently as females.37 This discrepancy may affect how swearing is perceived.26,37 It has also been found that females may need to exhibit a higher degree of professionalism compared to males to be considered credible in certain situations.38 Race is a less studied social variable within the swearing research.7 Caucasians, in particular, tend to swear in a wider range of social situations than other racial groups, and they typically face less severe judgement for their language.7 This suggests that the racial identity of a physical therapist who swears may have implications on the outcome.

The utility of strategic swearing in healthcare settings is underrepresented in the literature.39 In mental health settings, Giffin11 surveyed 50 patients who had experienced swearing from their therapist, which included social workers, counsellors, and psychologists. Surprisingly, 80% of patients reported that their therapist’s use of swear words had a positive effect on their therapeutic relationship, and over 88% of patients described an explicitly positive experience with their therapist swearing. These findings may be attributed to the informal, natural, and humanistic environment created by swearing, which allows the patient and provider to be more authentic.30 Swearing has also been shown to help build rapport40 and manifest solidarity.41 Interestingly, none of the surveyed patients by Giffin11 felt that their therapist’s swearing had a detrimental impact on their therapeutic relationship. These results are consistent with a recent case series in physical therapy that showed swearing by a physical therapist was not perceived as unprofessional and did not offend the patients.42

Where Do We Go From Here?

While this reflection revolved around exploring the potential positive effects of swearing, it is essential to clarify that we are not advocating the idea that swearing is universally beneficial, nor are we suggesting that every physical therapist should incorporate swearing in their practice. Instead, we recommend a prudent, mindful, and context-sensitive approach to swearing, or to refrain from swearing completely. Until we gain a comprehensive understanding of the mechanisms through which swearing serves positive functions, can effectively mitigate the risks of potentially offending someone with swearing, and gain a deep appreciation for which contextual factors are significant, it remains premature to justify the strategic use of swearing within a clinical setting. Further research is required to enhance our understanding of how swearing may be used to promote professionalism, patient-centered care, and the therapeutic alliance. Empirical evidence is a requisite to guide physical therapists on when, how, and if swearing can be used to enhance patient outcomes. Once such evidence becomes available, swearing may indeed emerge as a strategy to help meet our professional vision of “improving the human experience.”43

Authors’ contributions

NBW was responsible for concept development, design, and supervision. NBW, AM, GT, and RS were responsible for data collection and reflection, drafting and editing, and approving manuscript prior to submitting.

Acknowledgements

We extend our deepest gratitude to Ashley Kappel, whose invaluable contribution transcends conventional acknowledgments. Ashley provided an initial example of patient-centered strategic swearing that not only served as the guiding genesis behind this manuscript but also sparked our interest in exploring the depths of what professionalism truly means.

References

  1. Stephens R, Spierer DK, Katehis E. Effect of swearing on strength and power performance. Psychol Sport Exerc. 2018;35:111-117. doi:10.1016/j.psychsport.2017.11.014
  2. Stephens R, Umland C. Swearing as a response to pain-effect of daily swearing frequency. J Pain. 2011;12(12):1274-1281. doi:10.1016/j.jpain.2011.09.004
  3. Stephens R, Atkins J, Kingston A. Swearing as a response to pain. Neuroreport. 2009;20(12):1056-1060. doi:10.1097/WNR.0b013e32832e64b1
  4. Hostetter AB, Rascon-Powell DK. F@#k pain! The effect of taboo language and gesture on the experience of pain. Psychol Rep. Published online 2022. Available at: https://journals.sagepub.com/doi/full/10.1177/00332941221125776. Accessed October 30, 2023. doi:10.1177/00332941221125776
  5. Stephens R, Robertson O. Swearing as a response to pain: assessing hypoalgesic effects of novel “swear” words. Front Psychol. 11:723.
  6. Philipp MC, Lombardo L. Hurt feelings and four letter words: swearing alleviated the pain of social distress. Eur J Soc Psychol. 2017;47:517-523.
  7. Beers Fägersten K. Who’s Swearing Now? The Social Aspects of Conversational Swearing. Cambridge Scholars Publishing; 2012.
  8. Rassin E, van der Heijden S. Appearing credible? Swearing helps! Psychol Crime Law. 2005;11:177-182.
  9. Daly N, Holmes J, Newton J, Stubbe M. Expletives as solidarity signals in FTAs on the factory floor. J Pragmat. 2004;36:945-964.
  10. Stapleton K. Swearing. In: Interpersonal Pragmatics (Handbook of Pragmatics 6). De Gruyter; 2010:289-306.
  11. Giffin HJ. Clients’ experiences and perceptions of the therapist’s use of swear words and the resulting impact on the therapeutic alliance in the context of the therapeutic relationship. Smith Sch. Published online 2016. Available at: https://scholarworks.smith.edu/cgi/viewcontent.cgi?article=2787&context=theses. Accessed October 30, 2023.
  12. Jay TB, Caldwell-Harris C, King K. Recalling taboo and non-taboo words. Am J Psychol. 2008;121:83-103.
  13. MacKay DG, Shafto M, Taylor JK, Marian DE, Abrams L, Dyer JR. Relations between emotion, memory, and attention: evidence from taboo Stroop, lexical decision, and immediate memory tasks. Mem Cognit. 2004;32(2):474-488.
  14. Stephens R, Dowber H, Barrie A, Almeida S, Atkins K. Effect of swearing on strength: disinhibition as a potential mediator. Q J Exp Psychol. 2023;76(2):305-318. doi:10.1177/17470218221082657
  15. Stephens R, Zile A. Does emotional arousal influence swearing fluency? J Psycholinguist Res. 2017;46(4):983-995.
  16. Generous MA, Frei SS, Houser ML. When an instructor swears in class: functions and targets of instructor swearing from college students’ retrospective accounts. Commun Rep. 2015;28(2):128-140. doi:10.1080/08934215.2014.927518
  17. Code of Ethics for the Physical Therapist. Am Phys Ther Assoc. Available at: https://www.apta.org/siteassets/pdfs/policies/codeofethicshods06-20-28-25.pdf. Accessed August 12, 2023.
  18. Stewart M, Loftus S. Sticks and stones: the impact of language in musculoskeletal rehabilitation. J Orthop Sports Phys Ther. 2018;48(7):519-522.
  19. Pinto RZ, Ferreira ML, Oliveira VC, Franco MR, Adams R, Maher CG, Ferreira PH. Patient-centred communication is associated with positive therapeutic alliance: a systematic review. J Physiother. 58:77-87.
  20. Puentedura EJ, Louw A. A neuroscience approach to managing athletes with low back pain. Phys Ther Sport. 2012;13(3):123-133.
  21. Kittelson AJ, Hoogeboom TJ, Schenkman M, Stevens-Lapsley JE, van Meeteren NLU. Person-centered care and physical therapy: a “people-like-me” approach. Phys Ther. 2020;100(1):99-106.
  22. Dyer, C. Surgeon who shouted and swore at colleagues is suspended. BMJ. 349:g6349. doi:https://doi.org/10.1136/bmj.g6349
  23. Jovanovski V. Swearing Polish surgeon who rested his arms on patient during operation and stormed out of theatre is struck off. DailyMail.com. Available at: https://www.dailymail.co.uk/news/article-2103474/Swearing-Polish-surgeon-rested-arms-patient-operation-stormed-theatre-struck-off.html. Accessed July 14, 2023.
  24. Zhou Y, Callejas MLA, Li Y, MacGeorge EL. What does patient-centered communication look like? Linguistic markers of provider compassionate care and shared decision-making and their impacts on patient outcomes. Health Commun. 2023;38(5).
  25. Davies M. Is it OK for doctors to swear at work? BMJ. 2015;350:h383. doi:https://doi.org/10.1136/bmj.h383
  26. Jay T, Janschewitz K. The pragmatics of swearing. J Politeness Res. 2008;4(2):267-288.
  27. Fiester A. The “difficult” patient reconceived: an expanded moral mandate for clinical ethics. Am J Bioeth. 2012;12(5):2-7.
  28. Acero RCL. Swearing Circles: A Proposal for Dealing with Stressful Events, Because $#!+ Happens. 2022;(1). Available at: https://jps.library.utoronto.ca/index.php/cjtmhd/article/view/38306/29207. Accessed October 30, 2023.
  29. Washmuth NB, Stephens R, McAfee B, McAfee AD, Bise CG, Durham J. Using expletives to enhance therapeutic outcomes: A case report. Health Psychol Res. 2023;11:89726. doi:doi:10.52965/001c.89726
  30. Vingerhoets AJJM, Bylsma LM, de Vlam C. Swearing: a biopsychosocial perspective. Psych Top. 2013;22(2):287-304.
  31. The associated press profanity study. Ipsos Public Affairs. Published 2006. Available at: https://www.ipsos.com/sites/default/files/news_and_polls/2006-03/mr060328-2.pdf. Accessed October 30, 2023.
  32. Williams IL, Uebel M. On the use of profane language in psychotherapy and counseling: a brief summary of studies over the last six decades. Eur J Psychother Couns. 2021;23(4):404-421.
  33. Stapleton K. Swearing and perceptions of the speaker: a discursive approach. J Pragmat. 2020;170:381-395. doi:10.1016/j.pragma.2020.09.001
  34. Fine MG, Johnson FL. Female and male motives for using obscenity. J Lang Soc Psychol. 1984;3:59-74.
  35. Burns MC. Why we swear: the functions of offensive language. Monash Univ Linguist Pap. 2008;6(1):61-69.
  36. Reisenwitz TH, Iyer R. Differences in generation X and generation Y: implications for the organization and marketers. Mark Manag J. 2009;19(2):91-103.
  37. Guvendir E. Why are males inclined to use strong swear words more than females? An evolutionary explanation based on male intergroup aggressiveness. Lang Sci. 2015;50:133-139.
  38. El-Alayli A, Hansen-Brown AA, Ceynar M. Dancing backwards in high heels: female professors experience more work demands and special favor requests, particularly from academically entitled students. Sex Roles. 2018;79:136-150.
  39. Washmuth NB, Stephens R. Frankly, we do give a damn: improving patient outcomes with swearing. Arch Physiother. 2022;12.
  40. McLeod L. Swearing in the “tradie” environment as a tool for solidarity. Griffith Work Pap Pragmat Intercult Commun. 2011;4:1-10.
  41. Baruch Y, Jenkins S. Swearing at work and permissive leadership culture: when anti-social becomes social and incivility is acceptable. Leadersh Organ Dev J. 2007;28(6):492-507.
  42. Trummer G, Stephens R, Washmuth NB. A physical therapist who swears: a case series. J Rehabil Med – Clin Commun. 2023;6(10277).
  43. Guiding principles to achieve the vision. Am Phys Ther Assoc. Available at: https://www.apta.org/siteassets/pdfs/policies/guiding-principles-to-achieve-the-vision.pdf. Accessed July 12, 2023.


This work is licensed under a Creative Commons Attribution 4.0 International License.

About the Author(s)

Share this:

Browse and Search the JHR
DONATE
SPONSOR
Content
About the JHR

The Journal for the Humanities in Rehabilitation is a peer reviewed, multi-media journal using a collaborative model with rehabilitation professionals, patients and their families to gain a greater understanding of the human experience of disability through art, literature and narrative. The purpose of this interdisciplinary journal is to raise the consciousness and deepen the intellect of the humanistic relationship in the rehabilitation sciences.

Committee on Publication Ethics

Member since 2019 | JM14274

Subscribe

The Journal of Humanities in Rehabilitation offers a mailing list with periodic updates about new articles.

SUBSCRIBE
© 2018 Emory University. Authors retain copyright for their original articles. ISSN 2380-1069
Show Buttons
Hide Buttons