Compass

John Fuller Beckwith3/14/2024

In the world of lymphedema therapy there is an appropriate discussion about what constitutes the best care. Essays in this website address that question from a number of perspectives. During a recent focus group in which I was privileged to participate, this issue was a central discussion and the challenges of providing optimal care was discussed. A right and proper question was raised: when we find we can’t provide optimal care but see the need for skilled intervention to make a difference, how should we approach it? Should we as a profession develop a framework for alternative approaches in these cases? This is the question we should be grappling with since, despite not really hashing it out, therapists and individual patients are actually forced to deal with it every day. I know I face this question with each and every patient who walks (or rides) through my clinic door.

Any exploration of this question should very deeply consider what are the reasons gold-standard care can not be provided in each individual case. Many of the reasons can be identified and addressed, and some are more systemic and will need a more concerted and coordinated effort to remedy. This essay is not meant to fully identify or address all of those reasons, but to help put into perspective for the individual therapist how to approach the myriad cases in which delivery of optimal care is challenged by obstacles beyond the therapist’s or patient’s control.

I think it is helpful to think of lymphedema therapy like a compass. A compass helps assure that a person is headed in the right direction, that the individual is aligned in the best way with the target goal. In lymphedema therapy the end goal is the best reduction of lymphedema we can achieve. We know that any reduction is best achieved by following gold-standard therapy. So we can say the compass of therapy is aligned properly when we start out pointing our needle to gold-standard therapy. Like the metaphor of mapping a path in a geography with serious challenges such as mountains and canyons and fast-moving rivers, we may need to deviate from a direct path. But if our starting point of how to best treat each patient is by first applying the gold-standard, we know we are offering first and foremost the best option.

The alternative here is when therapists or organizations start from a minimalist approach, applying interventions piecemeal and in a something-is-better-than-nothing approach. This comes at the problem from the wrong end, ensuring that while they say they have done something the patient has not had a substantial improvement in the problem, so essentially it is a failed intervention. In a real sense, right from the beginning they have not aligned the compass in order to get to the desired goal!

A few examples from my practice: I often have patients express resistance to 5 or even 3 days per week therapy. Most come around, though not all certainly, because I am firm in that recommendation. I always say 5 days per week is preferred. But we will cut back to 3 days per week if transportation is an issue, if co-pays are an issue, if distance to/from the clinic is an issue (I see many patients who live more than an hour away). I prefer to fully treat thigh lymphedema, but often this is problematic so we make adjustments – not perfect but also not rigid adherence and providing flexibility in treatment planning and goals in order to meet the patients unique circumstances.

Any discussion of alternatives for gold-standard therapy should consider how the compass of therapy is aligned.