Institutional Barriers to Compassionate Care

In order to have a well-rounded and complete discussion of compassionate care, I don’t want to introduce new patient stories or continue sharing the myriad benefits without addressing institutional barriers to this type of care. One study reports that only 53% of patients feel that they receive compassionate medical care[1]. In the research that I’ve consumed so far, the main focus is on individual provider behaviors and their direct effects on patient outcomes. However, published articles about compassionate care have a lot to say about institutional barriers and the current culture in health care systems. Typically, insufficient time, insufficient personnel, and workload are seen to be contributors to decreased provider compassion.[2]

While most research on this topic comes from the nursing profession, it’s easily applicable to physical therapy because health systems and companies are usually set up with financial goals at the forefront. These goals shape each department’s policies and requirements. As a PT, if I work in busy a outpatient clinic with patients scheduled every 15 minutes, it’s impossible to sit down, have a conversation without simultaneous typing, and attend to a person’s needs without multitasking. If I work in the inpatient world, productivity (the ratio of billable time to total time on the clock) is often held up as the most important metric. When I worked as an inpatient PT, it was departmental policy across all the associated facilities to have our weekly productivity scores printed out and taped to the wall in the rehab office for all to see. Therapists who met the productivity requirement had their names and percentages highlighted in green. Therapists who were within 1-2% of the requirement had their names and percentages highlighted in yellow. Therapists who were more than 2% away from meeting the productivity requirement had their names and percentages highlighted in red. At the bottom of the print out, the calculated average productivity score for the team was listed. This average team score was linked to whether or not the entire team could get an annual bonus. Our individual productivity scores were linked to whether we were eligible for an annual raise. The combination of public shaming and financial incentives sent a very clear message: your value as a PT is in making money for this company, and there is no room in your job for anything that might take away from this end goal.

One problem is that health care billing is centered around doing things. I can bill for having patients exercise, practicing mobility skills, and teaching them how to be safe. Because so called “soft skills” like compassion are difficult to quantify, they are not able to be itemized in therapy billing, and are therefore deemed unnecessary by systems that focus on the bottom line. Because I also cannot bill for the stacks of paperwork that I’m required to complete for each patient encounter, most therapists (myself included) have to type while they listen in order to keep up – combine the non-billable activities to cut down on time “wasted”. Unfortunately, human brains are not good at multitasking, so we miss important details this way. Additionally, if a therapist is typing, he isn’t making eye contact and participating in active listening, 2 of the 5 identified behaviors that make patients feel as though they’ve had a compassionate interaction. This is not to say that it’s unethical or unkind to get your paperwork done and be efficient at work. However, these types of time constraints combined with the lack of monetary compensation available for providing interventions such as compassionate communication do lead to the devaluing and reduction of compassion circulating through our health system.

When health systems prioritize financial goals above all else, they prevent the delivery of compassionate care, which actively undermines their other patient centered goals (like pain medication usage and patient satisfaction scores). If I see that my patient has an issue that prevents participation with therapy, but I also know I might be publicly shamed and financially penalized for spending too much time talking to nurses or doctors about the patient's needs or for taking care of the patient’s needs that don’t fall under the umbrella of “billable therapy”, there is a real ethical dilemma. I’ve been incentivized to either ignore the patient’s needs and leave early for the day to maintain my productivity ratio or heartlessly try to force the patient to do some minimal participation that isn’t functionally beneficial but is billable. But, I know in my heart that compassionately taking care of the patient's needs - actively listening to what they have to say and working to resolve issues - while accepting the nasty emails to follow is the ethically sound choice. The paradox is that compassionate care would help patients meet their own goals faster, heal better, and participate more with therapy, all of which would be financially beneficial to the health system.

With the system designed as it is, it’s actually a wonder that anyone receives compassionate care. Health care systems take advantage of the immense altruism that providers carry into their practice, counting on the fact that providers will do their best to provide some level of compassion to their patients even at the expense of public shaming, berating by managers, and personal financial loss. If we are to truly practice evidence based medicine and include compassion as a teachable, skilled, and effective intervention for our patients, some changes will have to be made in the way that therapy (and other disciplines’) services are reimbursed. Additionally, health systems would be wise to recognize that sometimes hiring a few extra staff can alleviate time and workload constraints, leaving every provider additional space to provide compassionate care, which would result in protection against adverse health outcomes, improved patient satisfaction scores, faster wound healing, decreased pain medication usage, quicker discharges, and decreased provider burnout.

By illuminating barriers to compassionate care, we can begin to see that providing compassion to patients is a systems wide issue that is broadly influenced by health system administration, upper management, and even federal billing rules. It would be interesting to see research comparing compassionate care provided in differently structured health systems to see the degree to which this plays a role in the individual behaviors of providers. If anyone has read a study about this, please send it my way!

[1] An agenda for improving compassionate care: a survey shows about half of patients say such care is missing. https://pubmed.ncbi.nlm.nih.gov/21900669/ [2] Compassionate care: benefits, barriers, and recommendations. https://jag.journalagent.com/phd/pdfs/PHD-88557-REVIEW-PEHLIVAN[A].pdf