#Physicaltherapy Cares More: Other ingredients


Greatly appreciate the comments and in particular the excellent resources from my last post.  We are in a series of posts (here, here, and here for prior) called “Cares More” an initiative for physical therapists to regain or maintain their calling and meaning within the profession, provide a series of evidence based factors that are non “hands on” per se and differentiate us from other healthcare providers. 

 The last post was on empathy-likely the “secret sauce” of care. To summarize, The research does show that one can lose empathy, regain empathy, enhance empathy, be instructed in empathy, and have legitimate deficits in empathy.  As it turns out empathy is more complex than our initial “blink” and this is where we need to encourage instruction in empathy.  There are really 3 stages of empathy (Zaki & Ochsner, 2009)-unfortunately as healthcare providers, we only think of this construct in one way-putting ourselves in another’s shoes.  The first stage is “experience sharing”, essentially the emotional component when we “feel” someone else’s emotion (pain, discomfort, predicament) as if they were our own.  The second stage or “mentalising” is the cognitive consideration to those states, their sources, and trying to work through understanding them and finally, “prosocial concern” or having the motivation to act-reaching out, developing treatment plans, etc.  Said differently, empathy takes a warm heart, detached mind, and motivation.  In my experience, good providers are often very good at 2/3 but the best physical therapists 3/3!

However, Called to Care providers while seeing empathy as perhaps the secret sauce, should also recognize that it isn’t the only non “hands on” intervention ingredient in the significantly vast recipe. In this post, I will elaborate on two related concepts that have strong evidentiary support. My hope is that they become additional tools and resources for health care providers for all of the reasons brought up in the foundation post.

High Quality Connections

A critical component of the patient-therapist interaction is the connection or relationship that is established. An essential component of Called to Care is a thorough understanding of what high quality connections (HQCs) are and how they can be built and strengthened. Another component is insight into how people thrive at work (Dutton & Heaphy, 2008). It is also essential for physical therapists to collaborate with other staff and with their managers.

The energy and vitality of organizations depend on the quality of the connections between people in the organization. A focus on HQCs and their energy-generating capacities shows how small actions like respectful engagement can transform the energy between people (Dutton, 2003). The positive effect of HQCs is revealed by the feelings of both persons involved, what they do, and the beneficial outcomes they produce. HQCs can be viewed as dynamic, living tissue that exists between two people at work when there is some interaction involving mutual awareness (Berschied & Lopes, 1997).

Stephens and colleagues assert that HQCs deserve greater theoretical attention and base this assertion on four assumptions. First, they assume that humans are intrinsically social, have a need to belong, and make connections as an important aspect of their social experience. Second, they assume that connections are dynamic, changing as people’s feeling, thoughts, and behavior changes when they interact with one another. Third, work is performed through social processes, and connections are key elements for understanding how work is accomplished. And fourth, they assume that connections vary in quality (Stephens, Heaphy, & Dutton, n.d.).

Connection quality is marked by three subjective experiences. First, connection quality is sensed by feelings of vitality. People in a HQC are more likely to feel positive arousal and a heightened sense of positive energy (Quinn & Dutton, 2005). Second, the quality of a connection is felt through a sense of positive regard (Rogers, 1951). Being regarded in a positive context connotes feelings of being loved, respected and cared for in a connection (Stephens, Heaphy, & Dutton, n.d.). Finally, the subjective experience of a connection’s quality is marked by the degree of mutuality. Mutuality captures the shared vulnerability and responsiveness that both people feel when they are fully engaged in a connection (Miller & Stiver, 1997). These three subjective markers help explain why HQCs are experienced as attractive and pleasant and why they are life-giving (Stephens, Heaphy, & Dutton, n.d.).

Research has shown that HQCs improve individual functioning through cognitive, physiological, and behavioral processes. For example, it has been shown that even a few interactions with others can improve both persons’ cognitive performance (in speed of processing and working memory performance) (Ybarra et al., 2008). Furthermore, medical evidence shows that even brief interactions at work can have salutary effects on people’s cardiovascular, neuroendocrine, and immune systems (Heaphy & Dutton, 2008). Research also shows that HQCs facilitate an individual’s recovery and adaptation when suffering from loss or illness (Lilius, Worline, Maitlis, Kanov, Dutton, & Frost, 2008). Furthermore, HQCs are an important means by which individuals develop and grow (Ragins & Verbos, 2007).

HQCs are vital to the energy of any organization, and are marked by measurable positive feelings. The empirical evidence on the psychological, physiological, and behavioral benefits of HQCs, as taught to physical therapists and incorporated in clinical and work contexts, are core to the success of Called to Care.

Broaden-and-Build Theory

Fredrickson’s (1998) broaden-and-build theory of positive emotions is part of Called to Care because of its potential benefits to patient, physical therapist, and workplace dynamics. The theory says that positive emotions broaden thought-action repertoires, enabling individuals to be flexible on higher-level connections and consider wider than usual ranges of percepts, ideas, and actions. The broaden-and-build theory of positive emotions says that broadened cognition enhances flexibility, that in turn and over time builds personal resources, including mindfulness, resilience, social closeness, and even physical health (Cohn, Fredrickson, Brown, Mikels, & Conway, 2009; Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008; Waugh & Fredrickson, 2006). The broaden-and-build theory combines hedonic well-being (the experience of pleasant emotions) with eudaemonic well-being (striving toward one’s potential and purpose in life). These are facilitated by accumulating psychosocial resources (Kashdan, Biswas-Diener, & King, 2008). The implication is that even though pleasant positive emotions are fleeting, they can have a longer-lasting effect on functional outcomes that in turn lead to enhanced well-being and connectedness. In this way, positive emotions expand people’s mindsets in ways that, little-by-little, reshape who they are (Garland et al., 2010, p. 850).

Broaden-and-build, if adopted by physical therapists and utilized in patient care interactions, may significantly impact the relationship and provide enhanced benefits outside of the physical therapy interventions.  Induced positive emotions increase people’s ability to be “one” or close with others (Waugh & Fredrickson, 2006, p. 850) and their trust in acquaintances (Dunn & Schweitzer, 2005).  Fredrickson and Losada (2005) suggest that a person’s affect and general well-being is represented by their “positivity ratio,” defined as the ration of their positive to negative emotions experienced over time.  Normal functioning has been characterized by positivity ratio of about 2:1 (Schwartz et al., 2002).  However, patients in physical therapy may have medical conditions that subject them to a negativity bias, where negative emotions, events, and problems command the attention and prevent individuals from assessing situations evenhandedly (Rozin & Royzman, 2001). This suggests that in order to overcome the potency of negative emotions, positive emotions need to outnumber them by more than the 2:1 (normal functioning).  Losada and Heaphy (2004) have identified 3:1 as the tipping point ratio above which optimal functioning emerges.  This was further tested by Fredrickson and Losada (2005), who found that when the ratio is above 3:1, people experience the broaden-and-build effects of positive emotions and demonstrate goodness, growth, and resilience. When the ratio dips below 3:1, positive emotions are insufficient to support optimal functioning and might languish (Keyes, 2002).  While recent commentary (Brown, 2013) have questioned some of the math behind 3:1, there is ample supportive evidence for a ratio greatly exceeding positive to negative.

Two other significant effects of the “Losada ratio” are important to physical therapists as they influence physical health components.  Fredrickson and Levenson (1998) have shown that positive emotions—both amusement and contentment—can speed cardiovascular recovery from anxiety and fear. Perhaps even more significant, positive emotions have been shown to help patients rebound from adversity and cardiovascular reactivity, ward off depressive symptoms, and continue to grow (Fredrickson, Tugade, Waugh, & Larkin, 2003; Ong, Begeman, Bisconti, & Wallace, 2006; Tugade & Fredrickson, 2004).  The mounting evidence of the benefits of broaden-and-build theory make it a core component of Called to Care.  Armed with shaping expectations, empathy, high quality connections, and broaden and build as a core foundation, physical therapists are in a unique position to influence care.



8 responses to “#Physicaltherapy Cares More: Other ingredients

  1. Anne Weiler says:

    Patients have told us that one of the motivating factors in using Wellpepper to improve exercise adherence is knowing that their physical therapist is watching their progress. The relationship between the healthcare provider and patient is a key motivator in recovering and maintaining wellness.

  2. Larry,

    What a great post! Creating great patient relationships requires physical therapists to do precisely what marketing gurus like Greenberg and Mayer, along with sales professionals like the great Zig Ziglar have done for years- namely to first of all truly understand empathy as you have described it, and secondly to balance such empathy with our own egos. This is the really tough part for most of us and requires constant reinforcement and training.

    Third, we need to understand(once again as sales and marketers understand) the importance of asking open-ended questions(tough when you are looking at the “Medicare Clock”), and using the concept of reflective listening.

    Also, as you point out, learning these skill sets really helps in all aspects of life, and for PTs specifically in the area of Public Relations and developing relationships with numerous sources of business.

    The basis for all of this, lies in a good understanding of how the human mesolimbic system operates. The truly interesting thing about understanding neurotransmitters like dopamine and other endogenous substances such as endorphins is that PTs, perhaps more than any other healthcare providers, are in the best position to utilize the mesolimbic system. As the manual therapists know, spinal and peripheral joint manipulation can effect the release of beneficial endogenous substances, as can the type and intensity of exercise.

    Taking all of the above a step further in relationship building, catecholamines and serotonin uptake can be influenced by words of praise, as you alluded to,colors in the clinic, ingestion of caffeine, a smile,and especially a good laugh.

    I think that we are truly on the cutting edge of using empathy in relationship building, and that a healthy understanding of all that you wrote about will result in a far more effective PT and perhaps just as importantly in a masterful PR person with the ability to circumvent third party payers and convince patients that we have far more to offer than what insurers are willing to pay for.

    James Glinn SrPT

  3. Selena Horner says:

    Out of curiosity… if you were to think about the various variables/factors affecting outcomes in physical therapy services, what do you believe is the strength of the effect empathy and relationships may have have on the final outcome? How does this compare to the various interventions that are billed out as procedural codes?

    1. Larry says:

      It is very hard to determine but the non clinical factors significantly influence in a variety of ways. Placebo/Nocebo have the most research around them-most relevant to PT is shaping expectations. In fact, any physical therapy research in (or any medical for that matter) that primes or gives indication to the patient about expected results should be viewed with great suspicion-that is how powerful those effects are. If you believe the largest survey data (Press Gainey which is going to be used in Obamacare) these factors are more important than clinical outcome. This is not to suggest that EBP and best evidence interventions are not factors-they are but in my view PT’s have swung the pendulum to far in the “intervention-hands on skills” component and are far under weighing positive psychology and high quality connection factors (of which empathy is the most critical). In addition, the obscene documentation and retgulatory hurdles have contributed (as has coding) to influence care towards process rather than interactional. Patient values are huge and as we all know, a critical part of EBP.

  4. Selena Horner says:

    Okay… so now you are moving into expectations, which is different than empathy. So… what valid & reliable tools do we have that capture a patient’s expectations? How sensitive to change are they? And.. if implemented AND sensitive to change… I wonder… do they correlate with functional improvement in some sort of way? Again, just thinking out loud. (I think you’ve been privy to my big picture question/model a few years back… so I have a feeling you know what I’m thinking and why I’m asking.)

    The STarT is amazing in that scores do change, and quite quickly. It captures how thoughts/beliefs change IF done more than just at initiation of services.

  5. Larry says:

    The JOSPT provides a good intro to the placebo and patient expectations research. There are a ton of non-clinical indicators that have clinical effect. Remember the Boeing study? Often the best predictors are psychosocial factors. The non clinical ones that I explored in my thesis included empathy, shaping expectations, positivity, listening, compassion, various communication techniques, goal setting, etc. We are going to offer an online course on it soon.

  6. Dr Pullen says:

    I’m a family physician, and the feedback I get from patients who go thru PT is decidedly mixed. Often they love their therapists, get reasonably good results, and are very happy. Other times, often when they see different therapists at each visit, they feel they have been run thru a for-profit mill without much help. I try to choose my therapy offices carefully and get patient feedback.

  7. Dr. ullen,
    Here at Affiliates in Physical Therapy we see patients for an hour one-on-one. We believe that each patient should be seen by a licensed Pt or PTA and we work in teams. That way each patient interacts with the PT/PTA throughout their course of treatment. This individualized care allows us to get to know our patients on a more personal level allowing for improved quality of care. Many pateints have told us how other practices moved them around to multiple therapists and they did not care for that type of care.

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