Teachable AND Effective

When I think about patients with a long medical history, especially like the one I referenced in my last post, the take home message for me is that he might be in a different physical state today if his previous providers utilized compassion as an intervention the way that they utilize medicines, exercises, etc. This man had been treated for 24 years before we met, which is a lot of time to access and be affected by a medical system that prioritizes monetized interventions over “soft” skills like compassion and kindness. Arguably, most health care providers go into medicine in order to help people and alleviate suffering. So why don’t we learn the data about benefits of compassion for our patients?

Although they have been studied extensively in the past 20 years, the benefits of compassion on health outcomes are often underestimated. One study shows that in patients with diabetes, patients who receive care from a compassionate provider have a 41% lower rate of acute metabolic complications[1], and were almost twice as likely to have well controlled blood sugar over time[2]. These examples aren’t specific to physical therapy, but they do demonstrate that compassion plays a significant role in improving patient adherence to treatment protocols. And, in physical therapy, adherence to treatment protocols is a huge part of what we rely on for patient outcomes. We prescribe the exercises, behavior changes, etc, but the patients have to do the work.

In the therapy world, we rely on the “therapeutic alliance” to recruit patients to participate and buy into their therapy plan of care. Building this alliance creates trust between patient and therapist, and demonstrating compassion during the initial evaluation visit is critical to creating this alliance. Even though this concept is taught in therapy school, there is very little information presented about HOW to effectively demonstrate compassion in order to create a therapeutic alliance. Because medical training programs typically do not offer that type of training, here is how things have historically played out for my patient.

My patient typically encounters providers who stare at their computer screens, typing, while he describes his decades long journey of loss of function and independence. Most frequently after this emotional exchange of information, rather than validating his grief over loss of function, or asking more questions to understand his daily routine, the provider says something to the effect of, “Ok, well let’s see how you do standing up!” At which point this patient shakes his head and reiterates his story…emphasizing the part where his wife now has to use a mechanical lift to get him in and out of his power wheelchair. The provider gets embarrassed, digs in, and makes this patient try to stand anyway. And then, a month later, after a few therapy visits and a home exercise program that prescribes non-functional tasks like supine short arc quads, these providers discharge him from therapy. They say things like “Well you haven’t made any progress with standing, and you still require a mechanical lift at home. Insurance won’t keep paying if you aren’t making progress.” He goes home feeling defeated, hopeless - with his personal goals unspoken and unmet.

Studies show that training physicians in compassionate behavior is effective in increasing patients’ perceptions of compassion, and it turns out that none of the five key behaviors are especially time consuming or complicated. This study[3] recommends sitting versus standing when speaking to patients, nonverbal expressions of caring (such as eye contact, touching a patient’s elbow, etc), detecting patients’ nonverbal emotional cues, recognizing and responding to opportunities for compassion, and verbalizing acknowledgement and support for the patient. None of these things are difficult to teach in a classroom or test in the way that programs test other necessary therapy skills. Imagine if every therapist, nurse, and physician had at least one lecture in school that stated, “If you do these 5 things when interacting with your patients, they will be twice as adherent to whatever protocol you set, they will require less pain medication – you can even heal their colds faster[4]!" I would have been floored by that information in school, and I have to think that students would be excited to know that they could increase the effectiveness of their interventions just by sitting, making eye contact, and acknowledging their patients’ personal stories. A final piece of compassionate care that I would like to include is the idea that our treatment protocols need to be achievable, and they need to address our patient’s actual goals for therapy. It is not kind or compassionate to set unachievable goals, or goals for things that our patients don’t see as a priority. Including a question such as “what do you hope to gain from physical therapy?” is a great addition to an initial patient visit.

If my patient had that kind of treatment from the outset, how might his disease course have been altered? Imagine if each therapist along the way had sat down, looked him in the eyes and said “Wow. I can’t imagine how frustrating that must be for you. What are some things you’d like to work on with me to increase your independence?” Some changes are obvious, like writing goals in small enough increments for him to show progress and continue attending therapy, or working on things like self feeding that are achievable and might make a huge difference in his life. We will never know some of the less measurable changes that might have been possible, like long term effects of compassion on his immune system[4] (his disease is thought to be autoimmune). He certainly would have had more hope and less trauma induced by the medical system.

I am interested to know how many medical programs (physician, therapy, nursing, or otherwise) teach the research about compassion impacting outcomes or the research about which behaviors come across as compassionate to patients. Evidence based medicine is a huge topic across all medical disciplines right now, and teaching students about compassion seems like an actionable way to include evidence that might make a huge and immediate impact on patient care.

[1] The relationship between physician empathy and disease complications. https://pubmed.ncbi.nlm.nih.gov/22836852/#article-details [2] Physicians' empathy and clinical outcomes for diabetic patients. https://pubmed.ncbi.nlm.nih.gov/21248604/#article-details [3] Curricula for empathy and compassion training in medical education: a systematic reivew. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705835/ [4] Practitioner empathy and the duration of the common cold. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720820/