Avoiding Dehumanization

In the clinic where I work, we have a steady stream of PT and athletic training students. It’s fun to be in an environment where we get to teach by example and plant seeds in the minds of future clinicians. I have detailed and specific memories from my clinical experiences, and some of the practice ideals that I cling to most tightly come directly from my clinical instructors. One therapist led by example to teach me that, especially for patients with rare or complex diagnoses, it’s ok to admit that I don’t have all the answers. Another therapist led by example in telling patients difficult but honest information that was crucial for making plan of care decisions. Yet another showed me that tapping into a patient’s motivation is the best way to recruit participation, even if that patient is only motivated to get on to the toilet.

I think a lot about what I want students to remember from their brief time with me, especially considering that I have a mix of very different, quirky patients. My patients have a wide range of diagnoses, and an even wider range of life experiences and personalities. It can be difficult to slingshot from a young adult with cognitive and physical impairments who loves to go to clubbing, to a middle aged man who is dependent for all mobility who loves to discuss near death experiences, to an elderly man with relatively few impairments who wants to reminisce about his life. I spend a lot of time filling the students in about my patients’ medical journeys and personalities, as well as their long term goals. Then, yesterday, I read about a wild study in Compassionomics (which I highly recommend for anyone who interacts with the healthcare system either as patient or provider). The researchers asked patients in the emergency room what their biggest concern was, and then compared these answers with the patients’ chief complaints, or reasons for presenting to the emergency room in the first place. Their chief complained matched their biggest concern only 26% of the time[1].

Most of the time, from the examples provided in the study, patients were most worried about something tangentially related to their chief complaint. For instance, someone whose chief complaint was “chest pain” might be most worried about dying of a heart attack before his children reached adulthood. It’s easy to treat people from an emotional distance when faced only with their medical complaints. When we know their deepest concerns, however, it makes dehumanizing patients almost impossible.

It’s understandable to see how employees in a busy emergency room could miss this. When someone requires emergency resuscitation or immediate and life saving triage skills, it’s easy to believe that someone might forget to ask “but what is the biggest concern in your life right now?” In a therapy setting, however, we spend a longer amount of time getting to know patients, and we have plenty of time to get to the heart of a patient’s concern rather than just treating a body part. And yet, I can think of an almost unlimited number of examples where I have seen patients treated as just their diagnoses, rather than as actual humans whose lives are impacted by their diagnoses.

So why do we avoid asking the real question, using the “chief complaint” as a proxy for a patient’s most important concern? Sometimes, it’s because we are too busy taking care of the logistical aspects of our jobs to slow down and ask the humanizing questions. But sometimes, I think we’re scared to hear the answers. I think we are afraid that a patient’s deepest concerns might be too painful to receive. Research shows that being able to tolerate distress is a core competency for compassionate engagement[2]. Additionally, there is a lot of research about fear of compassion being correlated with maladaptive perfectionism (i.e. perfectionism that gets in the way and includes setting unrealistic standards, overreacting when not reaching such standards, and needing always to be in control[3]). Anyone who has gone through medical training can attest that maladaptive perfectionism is pervasive. If we have fear of compassion for ourselves or for others, it can seem like a psychologically dangerous move to active seek and engage with a patient’s distress. It’s easier to focus on the ACL tear than the athlete grieving the loss of her senior season.

Functional MRI research shows that, when a person feels empathy, the pain centers of their brain are active even though they aren’t sustaining an injury. We may instinctively avoid situations that are painful and require real empathy as self preservation. However, fMRI research also shows that, when a person feels compassion, the reward centers of their brain are active. It is the process of acting on that empathy which turns pain into reward in our brains. Acting to relieve another’s distress makes it possible and even rewarding to sit with them during their distress. It’s one of the best parts of physical therapy (and probably the medical field as a whole) – we are uniquely trained and positioned to be able to ACT to relieve suffering. But, if we avoid asking hard questions because we are afraid to sit with people giving hard answers, we will never get that neurochemical reward of acting compassionately, and our patients will never get the optimal outcomes that can be achieved when combining best technical practices with best interpersonal practices.

And sometimes, patients’ concerns do not match their providers’ goals.

Once, I had a patient come to me for chronic tailbone pain. After several sessions, she shared with me that she had been incontinent of bowel and bladder for several years. Seizing upon what I thought would be a valuable change in her quality of life, I offered to include bowel and bladder goals to her plan of care. To my immense surprise, she declined! She felt that her tailbone pain was her biggest concern, as it was affecting her ability to perform her job duties, and that she wasn’t feeling great distress about her loss of continence. I could not relate to that at all (and honestly I still don’t get it), but by asking about and then ACCEPTING her stated priorities without judgment, she was able to find the relief and quality of life improvement that she had been seeking.

I think this is what I want students to take away from their time with me. Ask patients about their deepest concerns. “What are you worried about most?” is a great way to not only let patients feel heard, but also a great way to find out what to prioritize in future treatments and in long term goals. In actively seeking to humanize our patients, we can reap the sweetest rewards of the therapeutic alliance AND provide optimal care.

[1] “Beyond the Chief Complaint: Our patients’ Worries”. https://link.springer.com/article/10.1007/s10912-017-9479-8 [2] https://jcompassionatehc.biomedcentral.com/articles/10.1186/s40639-017-0033-3 [3] https://study.com/academy/lesson/adaptive-vs-maladaptive-perfectionism.html#:~:text=Maladaptive%20perfectionism%20is%20perfectionism%20that,always%20to%20be%20in%20control.