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When a patient undergoes rehabilitation for disabling injuries, do the rehab clinician’s goals match the patient’s goals?
That’s what researchers at the University of Pennsylvania Health System wanted to know when they developed a board game that helps doctors and patients entering rehabilitative regimens to clarify demands and expectations of treatment.
"Understanding differences in perceptions between clinicians and patients is essential to achieving optimal outcomes," says Margaret G. Stineman, MD, associate professor of rehabilitation medicine at the University of Pennsylvania Health System in Philadelphia and lead author of the study.
In addition to revealing differences between the goals of clinicians and patients, the study showed that there are differences in goals between patient groups depending on their gender and environment. For example, women value grooming and want to control the way they look and appear to people, while men tend to value their mobility more. Participants in Philadelphia valued stair climbing more than participants in Houston, revealing that their decisions were based on the architecture of the buildings in their community.
At the time of a disabling injury, patients are faced with many choices. While clinicians need to provide information grounded in their knowledge, patients must make their choices according to their life experiences and the environment in which they live, says Stineman.
The board game is based on several theories and scientific thought including economic theory. Basically, people must make trade-offs. Just as they would have to decide whether to go to the movies or buy a hamburger if they only had $5, they must choose between different functional activities. "During the game you can choose to improve the ability to manage your bowels and bladder, but if you choose to do that you will have to accept greater dependence in eating, walking, or remembering," says Stineman.
When playing the game, each participant is asked to move a peg forward one notch for one of 18 functional skills. Their choices include such activities as eating, bathing, dressing, and bowel and bladder control.
Each category starts out with maximal assistance, which means that the disabled person can’t do the task at all, and progresses through seven levels. The final level is that the person requires no assistance to complete the task. In the first stage of the game, each player gets 18 moves, at which time he or she can move a peg from any category, even repeating categories during a turn.
During the free-form phase, when participants make their initial moves, no one is allowed to speak. They are only allowed to move their pegs. "The reason is to be sure there is no one person who dominates the group. We wanted to make sure that all people are contributing equally," explains Stineman.
In the second phase, each participant views the board as it stands and determines which function he or she would like improved upon. For example, the player may want to be able to eat with less assistance from another person. Players are allowed to move an item up one, but he or she has to move a different item back one to compensate for it.
During this phase, the team discusses each move and votes on whether the peg is moved or stays where it is. "The game creates a situation where people who are playing have an opportunity to express what they value and why they value it. They also hear what other people’s values are," says Stineman.
At the time of the study, four panels were involved in playing the game. Two panels consisted of clinicians only, and two had disabled patients. The reason the panels were separate is that the researchers wanted to look at the differences between consumers with disabilities and the professionals who care for them.
Since the study was conducted, Stineman has played the game during residency training programs to teach young doctors the value of choices relative to the functional status of disabled patients. She also has played the game at national meetings for physicians. There is a very large game board that can be seen from across a room during group presentations, and then a small version that can be played while participants sit around a table.
Although the game was created as a research tool, Stineman is considering making it a clinical tool. If patients played the game with family members, they would have an opportunity to discuss goals. It also could be played with the therapist and a patient.
"When we developed the game, I wanted to determine if the values were the same between people who are scientists and clinicians and have gone through an intellectual training half their lives, and the people they are serving — and also what the differences are. I think these are very important questions," says Stineman.