Effects of Compassionate Conversation

For several years, I treated patients with pelvic floor dysfunction, exclusively. I was nervous to enter that field of therapy. Pelvic floor specifics aren’t taught much in PT school, and the job requires not only a certain level of personal comfort discussing intimate bodily functions, but also the ability to put others at ease enough to actually discuss their full range of symptoms. In that practice setting particularly, I had to meet people where they were, in a nonjudgmental and normalizing way, or they would never return for a second visit. At this point in my career, I was familiar with the institutional barriers to compassionate care, and I was trying to find a practice setting in which those barriers might be less present. Instead, in pelvic floor therapy, I found a level of trauma caused by medical providers that shocked me. In the next few weeks, I want to highlight a few patient experiences that tie in with compassionate care research, demonstrating some areas for implementation of compassion as an intervention.

The first patient I want to remember called to schedule her appointment in tears. She called back several times each day leading up to her appointment to check and see if any earlier appointments were available. When I finally met her, she had become so distraught in the waiting room that she had to lie down in my office and was unable to complete the paperwork. She had a total hysterectomy with ovary removal 3 weeks prior and was experiencing symptoms that she found to be intolerable. She was having hot flashes, intense pelvic pain, constipation, and difficulty sleeping. She started calling her doctor’s office about 10 days after surgery, and to her dismay, they told her that she should be feeling back to normal about 2 weeks post-op, and that she sounded fine. She knew this was a huge change from her pre-surgery state, and felt strongly that she was not 4 days away from back to normal. So, believing herself to be VERY not fine, she did some intense Google research and came across pelvic floor therapy. She arrived as a direct access patient.

First of all, words matter. Telling someone “you’re fine, this is normal” on the phone while they sob into the ear piece is rude. Even if you know that what they are experiencing is not atypical, try saying “I’m sorry, you must be feeling awful. The symptoms you’re experiencing sound like typical hormonal changes resulting from your surgery, coupled with muscles tightening to protect your surgical site injury. If you're interested, you can pursue pelvic floor therapy to help manage your symptoms.” Normalizing is a powerful and compassionate tool. Telling someone “you’re fine, this is normal” is belittling and dismissive.

As it turns out, her symptoms were not atypical. She had extensive muscular guarding surrounding her surgical site, which is typical of all surgeries, pelvic floor or otherwise. Muscle guarding also increases when we believe that the pain we experience is dangerous, as this patient did. Unfortunately, pelvic floor tightness leads to constipation, difficulty initiating a urine stream, and pain with sitting, walking, etc. As we talked more, it turns out that no one had explained that after her surgery, she would be in “surgical menopause” – meaning that her body would undergo a typically long, gradual hormonal change in one instant. This was the cause of her hot flashes, night sweats, and insomnia. I spent the entire first visit providing education about her body, her hormones, and typical post-surgical healing. I educated her in breathing techniques for muscle relaxation and stress management. I taught her some constipation prevention strategies and the basics of bowel mechanics. She grew calmer throughout our visit, and, empowered with information about her own body, returned two days later in a much better mental state, reporting that she had actually slept longer than an hour or two for the first time since her surgery.

It may seem silly, or like a small thing to do, but teaching patients honestly and calmly about their bodies and about what to expect has a huge impact on patient satisfaction and healing. A 2016 study[1] shows that one 15 minute conversation between the patient and a nurse before ambulatory surgery, conducted compassionately and centered around the patient’s questions and concerns, alters many aspects of not only the patient experience, but also objective healing measures. Patients who received this pre-operative compassionate conversation reported decreased pre-op anxiety and decreased pre-op pain. After surgery, they demonstrated better surgical recovery, as evidenced by higher levels of daily activity, faster wound healing, and decreased pain. They reported high levels of satisfaction with the information provided during their compassionate conversation. My patient would have benefitted from this type of conversation, and much suffering would have been prevented!

If there were a pill that would decrease pre-operative anxiety and pain, surgeons would give it (and frequently they do give pain and anxiety related medications). If there were a pill that could simultaneously speed wound healing, decrease pain, and speed return to daily activity, as well as increase patient satisfaction scores, surgeons would definitely give it. Especially as reimbursement trends toward higher payments for faster and better results, an intervention that could provide all these benefits proves valuable. Compassion, in the form of time spent educating a person about her own body and addressing her specific concerns, IS this miracle intervention. However, what it requires, is an uninterrupted 15 minute conversation, which can be hard to come by in the current medical system. Maxed out staff to patient ratios don’t allow for it, insurance doesn’t pay well for it, and the technique is typically not taught in school, even though evidence based strategies have been identified for teaching compassionate communication (see my second blog post, Teachable AND Effective for these strategies). I have heard of some orthopedic groups providing this type of "class" for pre-op patients, but I saw enough traumatized post-surgery patients to realize this is not the norm, especially in pelvic floor cases.

There is a movement going on in the medical community right now called Trauma Informed Care. Its aim is to decrease traumatic experiences, like that of this patient, and to treat all patients with compassion and patience, assuming they may have been traumatized by the medical system in some capacity in the past. It's a huge topic right now in pelvic floor therapy, as well as in gender affirming medicine. I believe that compassionate strategies such as being direct and honest with patients about realistic expectations, as well as setting aside 15 minutes to hear and respond to their concerns align well with the mission of trauma informed care. By using direct and inclusive language, treating patients as the experts on their own bodies, and validating their experiences as well as their concerns, we can alleviate much suffering and achieve our goal in medicine - actually help people.

[1] Preoperative Anxiety in Ambulatory Surgery: The impact of an empathetic patient-centered approach on psychological and clinical outcomes. https://www.sciencedirect.com/science/article/abs/pii/S0738399115301324?via%3Dihub