One of the things I have been thinking about a lot recently is how vital it is that we communicate well with our patients. We are given the unique privilege and challenge of meeting someone, listening empathetically to their story, and trying to gain their confidence and trust enough for them to be comfortable with us touching them in intimate ways within just a few minutes of meeting us (for those of us who primarily practice in pelvic health even more so!). I think it’s easy for me/us to take for granted that, “of course this is how a PT eval goes-we listen to them, explain what we are looking for, and then proceed to touch their bodies”. My husband (non PT) will jokingly say sometimes that PTs lose any sense of a personal bubble because we are so used to touching and being touched.
However, this is not necessarily true for our patients, many of whom work in jobs that are not particularly touch heavy. Think about it, how many other contexts are there where a relative stranger will be allowed to palpate structures (many in sensitive areas), move your body, or ask you to move your body while scrutinizing you closely??
The longer I practice, the more I become convinced that communication is everything when it comes to the patient experience and patient’s comfort with our care. If they understand what we are doing and why, it becomes so much easier to be comfortable with this type of exam (and keep in mind, many doctors don’t do much of a physical exam any more, so it truly may have been a very long time since your patient has had something similar). This communication takes place in so many realms.
Non Verbal
The body language of the provider is so important when it comes to patient comfort. I have had multiple patients come away from their first session with me (or finish up their treatment time with me) and say with a sigh of relief “Oh, that wasn’t so bad! Thank you for making me feel so comfortable and relaxed.” When you keep in mind that my exams often involve intravaginal or intrarectal palpation (or both), I think that is saying a lot! When I have asked them what was helpful in creating this atmosphere of comfort, they have all said similar things-“You just acted like my problem was so normal! You were just so relaxed!”
I think we all know the basics of this-maintain eye contact, smile, actively listen and reflect, don’t cross your arms, limit how much you look at your computer screen and focus on the patient, etc. However, I have found it is also helpful to sit casually (nothing in between me and the patient), keep my face empathetic and appropriately reactive (I don’t show things like surprise, but I DO smile, nod, etc, keeping a “straight face” actually is a barrier to establishing a therapeutic relationship I believe). I also try to keep myself at the same “level” as the patient during the history taking portion of the exam to make sure I am not establishing a power differential-so I sit while I listen and ask questions, and I tend to sit or kneel for early objective measures as well (I usually start with musculoskeletal screening-SFMA movements, etc.).
I also try to be very respectful of the fact that patients may have strong emotions regarding what they are sharing with us. Things like struggling to walk through the grocery store can be very embarrassing. Heaven knows discussing sexual, bowel, or bladder dysfunction with someone you hardly know can feel awkward. So I maintain an open, empathetic manner (I truly do believe you can be both professional and communicate openness and empathy) and ask relevant questions in a calm way.
Education
I know it can be easy for me to forget that people who do not immerse themselves in the study of the human body every day often don’t know much about the way their bodies work. It is very obvious to me why I want to watch someone squat, or check hip joint mobility, or palpate for tenderness along the posterior pelvis, etc. (or even ask certain questions on the subjective exam) but to patients, these assessment techniques may feel random. Therefore, I tend to preface most things I do with an explanation. I pull out models and explain the exam I plan to do and why (fairly briefly and in patient friendly language), and then as I prepare to go through the actual exam, I remind them of what I had explained before (“Okay, this is the part where I am palpating this muscle where it runs this way.”). I also let them know that I would like feedback on how the exam feels because that is helpful information for me to have when examining them.
Now, I realize that this does need to be tailored to the patient to an extent-after all, if you have someone who has had chronic pain you don’t want to give education in a way that will cause them to fixate and perseverate more. However, I believe that you can still explain what you plan to do and why (“I will touch you here to do this test which is part of figuring out how to best help you”) is still possible. I use fairly vague terms in this portion of my education process, because I don’t want to “skew” test results, but I do still want them to know what I am doing and why-something along the lines of “I am checking your range of motion in your hip now because your hip and your back are very closely related” can be very helpful-again, keep in mind most of your patients don’t know this information.
I do a similar explanation process for interventions-just a very quick and basic explanation for why each element is included in their treatment progression; this exercise is to help stretch out that tight muscle in the back of your hips, this exercise is to help you with core coordination and control so that you will be able to move more easily, this manipulation is to help hit “reset” on the motor patterns in this area of your body so that we can more easily get your muscles working together. This is very helpful with home program compliance as well; if patients understand the why behind what you are asking them to do, they are more likely to do their homework!
The phrase “This is really common” can be very powerful for patients. As obvious as it sounds to us, letting people know that this is certainly not the first time we have heard this, we are comfortable with the information, and there is something we can do about it can really do a lot to set them at ease.
It Isn’t All About Me
One of the things that I really try to keep in mind with every patient interaction is that the care is about the patient, not about me. I am there to help them-which sometimes means focusing on education, other times on exercise, other times giving some “tough love” and helping them become their own advocate. Keeping this message in mind is really helpful when I am tempted to become defensive or assume that patients don’t have their own best interests at heart; it can be the difference between “Oh my goodness, this person is SO annoying. Why are they googling their symptoms and questioning me??” and “That is great that you are wanting to learn more about your body so you can advocate for your health. This is what I think is going on and why.”
Simple things like remembering that Sally was going to visit her grandkids this weekend, or that Tom was going to a job interview, or Sarah was going to run a half marathon and asking about it can make a world of difference to patients. It helps them really realize that you care about them as a whole person, not just their low back or pelvis.
I truly believe that much of our therapeutic impact happens from our entire interaction with the patient, not just from our skill in exercise prescription or flashy manual therapy techniques. Obviously these skills are vitally important, but the therapeutic power of a listening ear, empathetic/kind voice, and communication of “You are a very important individual part of my day, not just patient #452” can really enhance these skills and make the difference between a good/okay and great/extremely helpful visit in physical therapy. One of my mentors in the early part of my career liked to say “Patients don’t care how much you know until they know how much you care”-and I really find that holds true. Don’t focus on the mechanics so much that you lose the soft skills.
How do you establish caring relationships with patients? I would love to learn new tricks!
