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INTRODUCTION

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Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things—to help, or at least to do no harm. The art consists in three things—the disease, the patient, and the practitioner. The practitioner is the servant of the art, and the patient must combat the disease along with the practitioner.

—Adapted from Hippocrates, Epidemics, Bk. I, Sect. II

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It is clear that the expectations set by our patients, by society, and ourselves require us to do the best we can with each of our decisions. Imagine a large multispecialty outpatient practice. These four patients are on the schedule, each of whom has caused the patient's physical therapist to question the current plan of care.

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Ms. Swenson has been coming in for 3 weeks now, with little progress, and her therapist is beginning to wonder whether her heel pain is actually being caused by plantar fasciitis, as is stated on her referral from a physician colleague, or whether it might have a more central cause. The therapist remembers that he has had a few patients in the past month with severe heel pain related to spinal changes. The therapist has had only a few months' experience with lower-extremity orthopedic problems but has a colleague in the practice for whom it has been a specialty for about 3 years.

The Cho family is coming in with their grandmother, who speaks only Korean. The therapist has not been able to convince the patient that a regular aerobic exercise program is necessary to help her manage her low back pain. The therapist thinks it may be because her family will not let the therapist tell her that her back pain is a chronic, life-long condition that will need continual management. The therapist has become increasingly frustrated with what he perceives as the family's lack of cooperation and thinks today may well be a good time to discharge her if there is no further progress to be seen.

Mr. Washington, who had a stroke about 3 months ago, with some increasing depression, has shown great response to his therapist's use of repetitive tasks in the plan of care. Hand function has improved, the depression seems to be lifting, and the patient is quite pleased with the progress. However, Mr. Washington has not been keeping up with his co-payments for visits, as mandated by his insurance plan, and the therapist knows that Mr. Washington will reach his maximum visit limit in two more visits. Because both the patient and therapist see the progress being made, the therapist wants to arrange for a way to continue care, without taxing Mr. Washington's limited means any further.

When Mr. Davis came in 2 days ago he excitedly showed his therapist a printout from a Web site claiming that ultrasound would be a very successful intervention for his chronic ...

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