July 2015

DIABETIC FOOTWEAR: Cinematic symposium explores person-centric communication

7ISPO-iStock15629891-copyBy Jordana Bieze Foster

Cannes is the French city most often associated with cinema. But several hundred kilometers to the north, in Lyon, a pair of short films debuted in June that sent a clear message about the most effective ways for lower extremity practitioners to interact with their patients.

The videos, unveiled at the 2015 International Society of Prosthetics and Orthotics (ISPO) World Congress, were part of a symposium on person-centered communication related to therapeutic footwear. But the themes explored could be applied to virtually any aspect of lower extremity care.

“I think it’s really important for us to think about not just providing the best possible device, but also all those little bits and pieces that add up to a good outcome. We’re talking about footwear today, but I think these skills can be used anywhere,” said symposium speaker Ashley Morphet, cOP, a senior orthotist at Northern Health in Melbourne, Australia.

The scenario in each of the movies is the same: A 60-year-old woman with rheumatoid arthritis, played by a Dutch actress, comes to pick up a pair of custom therapeutic shoes from her practitioner, played by Klaas Postema, MD, PhD, who in real life is the head of the Center for Rehabilitation at the University of Groningen. Despite having been involved in choosing the design elements of her new shoes, the patient is disappointed when she actually sees them and hesitantly tells the clinician she doesn’t want to wear them. Where the two scripts differ is in the clinician’s response to the situation.


Before the viewing, symposium speakers discussed the importance of practitioner-patient communication for maximizing patient compliance, and touched on some key points to consider when having those conversations.

“There’s no pill you can give to a patient to guarantee acceptance,” said Jaap van Netten, PhD, a human movement specialist who is a senior researcher at Ziekenhuisgroep Twente in Almelo, the Netherlands. “You really have to communicate.”

As with any orthotic device that is visible when worn, one issue that can lead to noncompliance with therapeutic footwear is a reluctance to have a disability be so apparent. But footwear is a special case, van Netten noted.

“Therapeutic footwear isn’t just something new, it replaces something that is normally worn. Shoes don’t just solve a problem, they require the patient to get rid of something they like in exchange for something they like less,” he said.

Such visible evidence of disability also forces a patient to really acknowledge his or her disease—something that is difficult for many patients and can be another driver of noncompliance.

“The patient has to accept not only the shoes, but also the disease that is the reason for the shoes. If you do not accept your illness, you probably will not accept the need for shoes,” van Netten said.

A third factor that can affect compliance with footwear—or any other device—is a patient’s feeling that his or her concerns aren’t being heard or considered by the practitioner.

“The most important point is to make sure the patient is the one making the decision, based on your recommendation as a clinician,” Morphet said.

The two films touched on all of these compliance issues.

In the first version, the practitioner is all business, his attention focused on the shoes rather than the patient. When she expresses disappointment in the shoes’ appearance, he argues with her. “I don’t think they’re bad, I think they’re lovely,” he says in an accusatory tone. “These aren’t old people shoes, they’re very modern.”

After several rounds of this type of back-and-forth, the clinician makes it clear that the discussion is over despite nothing having been resolved. “Do you want to wear them now?” he asks, although it’s clear she doesn’t. “From my perspective we’re all done.”

The patient leaves, without the shoes and without paying for them, and the practitioner appears more irritated than concerned as the film comes to an end. It’s clear that this was an example for clinicians of what not to do with regard to communication.

In the second film, things go much differently. As soon as the patient expresses her disappointment, the clinician sits next to her, looks her in the eye, and appears to be genuinely concerned as they discuss the pros and cons of the footwear.

“I can see you’re very disappointed,” he says, without judgment. “And, if you look at these shoes for the first time, especially next to the more modest shoes that give you so many problems, yes, these new shoes would seem very different.”

Gradually, the practitioner refocuses the discussion on the patient’s pain.

“For you, it’s a major drawback how these shoes look,” he agrees. “But what kinds of things could you do in your life if you had less pain?”

She thinks about that, and ultimately reassesses the situation. “I guess I just have to accept it,” she says. “Now let me try them on.”

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