Blocking Rather than Engaging

A patient came back to therapy after yet another readmission to the hospital for dehydration. I could think of at least 3 times that he had been in such a situation in the preceding year. It would have been easy for me to ask him the basics of his hospital stay (dates, procedures, medication changes), and then to move on immediately to the physical exam. After all, it does take most of an evaluation to administer all the appropriate objective measures, especially when the patient has low activity tolerance from a recent hospitalization. But this time, instead of running through a traditional PT eval for an already known patient, I asked some different questions. I asked the patient if he had any ideas about why he kept getting dehydrated. When he admitted that he knows he doesn’t drink enough water during the day, I asked if there is a reason why he avoids hydration. He then shared that he has excruciating pain with urination. As it turns out, no one had ever asked him why he doesn’t drink enough, so he had never shared his avoidance behavior (or his urinary symptoms) with a medical provider.

Pain with urination is sometimes treatable with pelvic floor therapy, medications, or both, and luckily, since he confided in me, we are able to explore the options that he feels comfortable with. With decreased pain, he was able to comply with his hydration recommendations, and therefore stay out of the hospital. But it got me thinking – how many times do we stand in front of a patient, lecturing them about changing “noncompliant” behavior, when actually there is a real and valid reason why they are avoiding our well intentioned suggestions? A reason that remains undisclosed because no one asks…or seems to care.

I’ve been reading about provider communication all week because, while I’ve discussed the need for compassionate action, strong empathy skills, behaviors such as making eye contact, and interviewing strategies like avoiding interrupting the patient, I really haven’t delved into effective vs. ineffective communication in a health care setting. Last week, I discussed the Physician Belief Scale, and the ways that providers prefer clear cut, biomedical discussions and treatments. The week prior, I discussed perfectionism and the comorbid fear of compassion that many health providers face. This week, the article I’d like to discuss combines those topics to illustrate how my patient ends up with a lecture on drinking water every time he goes to the hospital without anyone asking him why he behaves the way he does.

Studies[i] show that “only half of the complaints and concerns of patients are likely to be elicited”. Patients withhold information for the following reasons:

-belief that nothing can be done

-reluctance to burden the doctor

-desire not to seem pathetic or ungrateful

-concern that it is not legitimate to mention them

-doctors’ blocking behavior

-worry that their fears of what is wrong with them will be confirmed.

It is interesting to me that patients feel that they should not burden their doctors with symptom complaints. If treatment is going to be effective, providers need to have the full picture. And, it is the responsibility of providers to create an environment where patients feel welcome to share, not like they are problematic for showing up to a medical appointment with symptoms! Providers are shutting down potentially fruitful conversations with patients by failing to engage.

In this article from 2003[ii], the authors describe physicians (but honestly I see this behavior everywhere in health care) as wanting to keep conversations squarely in their comfort zone – the patriarchal medical model, in which conditions have only biologic and no psychosocial components, and in which patients blindly accept recommendations from providers. The authors cite this behavior as due to “fear that [by focusing on social and emotional concerns] it will increase patients’ distress, take up too much time, and threaten [physicians’] own emotional survival”. Due to these fears, providers then respond to patients’ emotional cues with blocking rather than engaging. Blocking behaviors include

-offering advice and reassurance before the main problem has been identified

-explaining away distress as normal

-attending to physical aspects of care only

-changing the subject

-“jollying” patients along

These strategies shut down information sharing from the patient and actually serve to create distance rather than relationship and alliance between the patient and provider.

In order to provide effective communication, providers need to elicit patients’ problems concerns, give information, discuss treatment options, and be supportive. It seems that, if providers could work on eliciting the patients’ full list of complaints, they would be able to complete the other three tasks more easily. From providers, this will require mindfulness and reflection about their practice patterns. A provider with a high PBS score (indicating low comfort level with psychosocial complaints) might notice themselves engaging in blocking behaviors when patients begin to express distress about their symptoms, or when patients appear to be “noncompliant”. Patients, in turn, feel the discomfort of the physician, and interpret it as judgment, which leads them to clam up about further concerns. Similarly, a highly perfectionistic provider might demonstrate decreased compassion for a distressed patient, due to fear of compassion or fear that they may not react “perfectly” to a patient’s distress. A patient in this situation might feel like their concerns have no legitimacy or that they seem ungrateful for the care provided so far.

If we can practice noting when our own blocking behaviors are triggered during patient interactions, it will become obvious where we each need to do internal work. Personally, when I feel myself getting exasperated at a patient for being disengaged in our session, that’s actually my clue to start asking more questions. With the patient in my opening example, I felt exasperated that he had not been taking care of himself AGAIN. It was my clue to ask some personal questions about hydration and urination. With other patients recently, I have needed to ask questions about exercise difficulty and whether they felt our interventions were even helpful. At times, I have had to rephrase the question 5 times before I got a real answer. For me, exasperation is actually masking a feeling of vulnerability that something is not working in the patient’s treatment plan – that there is a missing piece. Sometimes it feels too hard to try to engage with that missing piece or to acknowledge that I may need to pivot our treatment. But, by engaging with that vulnerability and turning toward it, instead blocking my patient's concerns with jokes or more objective measures, I can improve treatment outcomes and decrease my own burnout. By staying open and courageously pursuing true honesty with patients, I reconnect with the reason I became a therapist in the first place – to actually help people, not just to run through a flowsheet of exercises.

I do realize that provider blocking behaviors feel like self preservation, especially in the overwhelming situation of health care today. The set up of most health care companies does NOT facilitate provider-patient connection. There are real barriers to providing this type of care. I will get into these next week.

[i] Silverman J, Kurtz S, Draper J. Skills for communicating with patients. Oxford: Radcliffe Medical Press; 1998. [ii] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124224/