Rarely do we talk about physiotherapy ethics. After completing a physiotherapy degree, further education is often anatomy based. As a result, there is little talk about ethical dilemmas facing physiotherapists.  It seems that ethical dilemmas arise in various forms.  Therefore, in this post we limit our discussion to those revolving around the complicated patient. 

First of all, there are many reasons why a patient may be viewed as complicated.  For example, patient characteristics.  These characteristics are demanding, game playing, or dishonest.  There are also external factors.  These include culture, family issues or poverty.  Of more obvious nature, there can be a complex history of medical problems, such as depression. 

Physiotherapy  can be a very rewarding career. Most go into physiotherapy wanting to improve people’s lives, regardless of how complicated a patient may be.  It may not always be possible to get the ideal patient but this is often not the challenge.  Often, the challenge is balancing the needs of your patient versus the clinic. 

Its true, clinics run tight schedules. Patient flow and satisfaction fuel clinic success.  Thus, initial assessment appointments range from 30-60 minutes. Yet, follow-up appointments are often 15 minutes. If the schedule is full, staying on time becomes crucial. But what happens when a consult runs over and you fall behind? 

In these situations, the stress of a long consult and the pressures of the admin staff weigh heavy (Potter et al., 2003). As a consequence, clinic staff may deem patients with severe pain, multiple injuries or complex medical histories as difficult. 

Bruckner (1987) describes this situation as “the dilemma of the double agent.”

Double agent

The Dilemma

The dilemma of the double agent is when “physical therapists encounter conflicts between loyalty to their patients and loyalty to their employers” (Potter et al., 2003). It often goes unaddressed in physiotherapy ethic courses. Essentially, the dilemma comes down to the perception of the physiotherapist.

“If physical therapists perceive themselves as agents of their patients, their employment may be threatened. If physical therapists perceive themselves as agents of their employers, their patients may suffer physical or psychological harm.” (Potter et al., 2003)

The dilemma impacts the therapeutic alliance, also known as the therapist-patient relationship. Finding balance between the patient’s and clinic’s needs is important for your patient’s full recovery.

Why Do We Face This Dilemma?

There are a variety of reasons therapists can mistakenly attribute the label  ‘complicated patient.’ One is the  patient’s characteristics (Potter at al., 2003) another can be a miscommunication between the therapist and patient.  Early assumptions or preconceived notions gained from the patients journal about the patient can contribute as well.

Synnott and colleagues (2015) explored the psychosocial factors associated with low back pain. Their research found that therapists only partially noted that cognitive, psychological, and social factors played a role in their patients’ pain. Instead, the therapists focused on more structural or mechanical aspects.

Stress, for example, may cause low back pain (Synnott et al., 2015).  Lifestyle choices may cause low back pain.  Low back pain it is not limited to structural or soft tissue issues.

When psychosocial factors go unnoticed, the therapist was found to view the patient as “demanding” and “attention-seeking” (Synnott at al., 2015). Patients were then labelled as complicated.  

This situation can snowball into low trust and slowed progress during treatment. Further, the therapist may be inclined to put the needs of the clinic ahead of their complicated patient.

Strategies For A Complicated Patient

Potter and colleagues (2003) came up with a variety of strategies to deal with a complicated patient. These include physiotherapy communication, behavioral modification and involvement of others.  Firstly, recognizing that a complicated patient may arise for a variety of reasons helps (Potter et al., 2003).

Physiotherapy Communication

To start, patients may feel misunderstood or may not understand you. Thus, it is crucial to develop effective communication skills. To start ask questions to get the whole picture.  Then explain and educate patients about their condition.  For example, you can create realistic anchor points by outlining the best and worse case scenario. Then set the goals of the treatment together.  This can be accomplished by including your patient in the planning process.  Explain to them how you are aiming to achieve the best case scenario.  By actively listening during this process you can build trust. The trust may encourage honesty in each subsequent consultation and help you identify the major issues needing to be addressed first.  Remember, trust is positively associated with patient satisfaction (Potter et al., 2003). If possible, perform follow-up calls or find ways to remain in contact during treatment.

Behavioural Modification

A positive physiotherapy and patient relationship is based on respect and trust (Praestegaard et al., 2011). Look for possibilities on how motivate and reward your patient. An example you can ask them to keep track of the exercises.  When an individual is in pain, they may act impatient or short.  In some cases, ignoring inappropriate pain behaviors is a good strategy to move them away from a pain focus. However, remember they have come to you for a reason. Positive reinforcement can help them with self-management strategies. These strategies may include daily exercises, self-massage techniques, or things like proper lifting techniques. Don’t be afraid to set a fee for missed appointments. This fee will motivate patients to show up and continue with their treatment plan. 

 Involvement of Others

Other factors may play a role in your patient’s pain levels or function.  So you may need to dig deeper.  Digging deeper can be achieved by referring your patient to other professions. For example, psychologists or occupational therapists. If you have a difficulty with your patient ask your colleagues for advice.  You can then weigh the advice and learn from their experiences.  The goal is that you get alternative strategies.  Also consider to use the admin staff at your clinic. If you notice a patient generally takes longer than the set 15 or 20 minute consult time, inform your admin staff. Have them schedule the patient for a longer consult

Request strategies and policies

A complicated patient does not have to become a persistent issue. Requesting and putting strategies and policies in place help prevent the dilemma of the double agent. As an example, using tools to help you understand a patient’s symptoms or explain symptoms to a patient can save time.  Better communication helps guide treatment plans and increases compliance and thusly, helps avoid ethical dilemmas.  A consciously ethic physiotherapist can still guide and administer treatment appropriately, helping patients achieve their goals and getting them back to their regular activities faster (Praestegaard et al., 2011).

Written and Edited by: Krista Bugden MSc. and Shellie A. Boudreau, PhD


Synnott A et al., (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy 61: 68–76.

Potter M., Gordon S., and Hamer P. (2003).The difficult patient in private practice physiotherapy: A qualitative study. Australian Journal of Physiotherapy 49: 53-61.

Bruckner J. (1987). Physical Therapists as Double Agents: Ethical Dilemmas of Divided Loyalties. Physical Therapy 67: 383-387.

Praestegaard J., and Gunvor G. (2011). The perceptions of danish physiotherapists on the ethical issues related to the physiotherapist-patient relationship during the first session: a phenomenological approach. BMC Medical Ethics 12:21.