By Jennifer Stone, PT, DPT, OCS
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 a person, listening empathetically to their story, and trying to gain enough of their confidence and trust for them to be comfortable with us touching them in intimate ways within just a few minutes of meeting (for those of us who primarily practice in pelvic health, even more so!). I think it is easy to take for granted that, “Of course this is how a physiotherapy evaluation goes—we listen, explain what we are looking for and then proceed to touch the patient’s body.” My husband (a non-physiotherapist) jokes that physiotherapists can lose any sense of a personal bubble because we are so used to touching and being touched.
How touching
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 in which 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’s experience and comfort with our care. If a patient understands what we are doing and why then it becomes so much easier for them to be comfortable with this type of examination (and, keep in mind, many doctors do not conduct much of a physical examination any more; it truly may have been a very long time since your patient has undergone something similar). This communication takes place in so many realms.
Non-verbal messages
The body language of the provider is vitally 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 a sigh of relief, saying: “Oh, that wasn’t so bad! Thank you for making me feel so comfortable and relaxed.” When you consider that my examinations often involve intravaginal or intrarectal palpation (or both), I think that is saying a lot! When I have asked what was helpful in creating this atmosphere of comfort, they all say similar things: “You just acted like my problem was so normal! You were so relaxed!”
I think we all know the basics of this—maintain eye contact, smile, actively listen and reflect, do not cross your arms, limit how much you look at your computer screen, focus on the patient and so on. I have found it is also helpful to sit casually (with nothing between me and the patient) and to keep my face empathetic and appropriately reactive (I do not show surprise, but I do smile and nod; keeping a “straight face” is, I believe, actually a barrier to establishing a therapeutic relationship). I also try to keep myself at the same “level” as the patient during the history-taking portion of the examination to ensure I am not establishing a power differential. So, I sit while I listen and ask questions, and I also tend to sit or kneel for early objective measures (I usually start with musculoskeletal screening, SFMA movements and so on).
Respectful and empathetic
I also try to be very respectful of the fact that patients may have strong emotions about the information they are sharing. Problems such as 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 believe you can be both professional and communicate openness and empathy) and ask relevant questions in a calm way.
Education leads to understanding
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 do not know much about the way the body works. 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 (or even ask certain questions on the subjective examination) but, to patients, these assessment techniques can feel random. Therefore, I tend to preface most things I do with an explanation.
I pull out models and explain the examination I plan to do and why (fairly briefly and in patient-friendly language) and then, as I prepare to go through the actual examination, I remind them of what I have already explained (“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 them to tell me how the examination feels, because that is helpful information for me to have when examining them.
Explain what you are planning
Now, I realize that this does need to be tailored to the patient to an extent—after all, if you have a patient with chronic pain then you do not want to give education in a way that will cause them to fixate and perseverate more. However, 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”). I use fairly vague terms in this portion of my education process because I do not want to “skew” the test results, but I do still want the patient to know what I am doing and why—something along the lines of “I’m checking the 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 do not know this information.
I undergo a similar explanation process for interventions—just a very quick and basic explanation for why each element is included in the treatment progression. For example, “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 the exercises you are asking them to perform then 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 do a lot to set people at ease.
It is not all about me
One of the things I 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 and other times on exercise, and sometimes giving “tough love” and helping the patient to become their own advocate. Keeping this in mind is helpful when I am tempted to become defensive or assume that patients do not 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 “It’s great that you’re 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 such as remembering that Sally was going to visit her grandkids this weekend, that Tom had a job interview or Sarah was going to run a half-marathon and asking about these events can make a world of difference to patients. It helps them to realize that you care about them as a whole person, and not just about their low back or pelvis.
I believe that much of our therapeutic impact arises from our entire interaction with the patient, not just from our skill in exercise prescription or 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 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 find that holds true. Do not focus on the mechanics so much that you lose the soft skills.
Jennifer Stone, PT, DPT, OCS is a board-certified orthopedic specialist and a CAPPA-certified pelvic health therapist. She writes for Evidence in Motion.
