Byline: Andrea Salzman, MS, PT
Megan is scheduled for aquatic therapy three times a week. Every time she shows, she sees a different clinician. During each session, her therapist-of-the-day perches on the deck, asplendid in corporate polo and khakis (“How hot he must be!” opines Megan), clipboard in hand, adding such clinical pearls to her session as “10 more”.
If another therapist happens to be poolside, an informal social pow-wow often commences, with both therapists vetting personal woes and work-based grievances in between glances pool-ward to ensure their wards continued some semblance of movement.
The only physical touch which ever takes place in her sessions occurred if it appeared likely that danger was in the mix. A wet deck might warrant a hand hold or an absent-minded arm wrapped around the gait belt (after all, those incident reports are such buggers to fill out).
Sometimes, during the very last moments of her 30 minute session, a mildly peeved Megan would ask the therapist what his name was, just to drive home the point that no one had bothered to share.
Megan was a remarkably generous soul. She was known in the neighborhood as the church lady who brought freezer meals for all the college students who were too far from home. And yet, it never occurred to Megan to bake her therapist a batch of brownies. In casual conversation, she never made use of the affectionately possessive “my therapist”. In actuality, she never talked about her sessions at all. Why would she? There was nothing remarkable (READ: nothing remark-worthy) to talk about.
At the end of 2 months of 2-3x/week aquatic sessions, Megan scored 6 points higher on her Berg scale, her Timed Up and Go had improved by 4 seconds, and her 6 minute walk distance had improved by 50’. And if you asked Megan what she thought about her bout of therapy, she would have told you the truth: it was a bust.
The truth of the matter is, patients who make functional improvements with therapy, but who are unhappy with the care they receive, do not find therapy to be of benefit. And it’s not just a subjective feeling of malaise. This subjective discontent boils over into the realm of physical improvement. The former colors the latter.
In other words, in order for therapy to be maximally effective, therapists need to care whether their patients are satisfied with their treatment. And, to be blunt, this can be translated in almost every situation to whether their patients are satisfied with their therapist.
Patient Satisfaction Versus Treatment Outcome
There have been several studies which examined the precarious relationship between patient satisfaction and functional improvement. Beattie et al1 put it this way:
Maximizing patient satisfaction is a sound philosophy from both a clinical perspective and a business perspective. Satisfied patients are more likely to adhere to treatment and to continue to seek health care at a given facility.
Our findings indicate that adequate time spent in patient care and the professionalism of the therapist and clinic staff are more important for patient satisfaction than are the location of the facility, the quality of equipment, and the availability of parking.
We believe that, in the current health care environment, the emphasis on cost-cutting, high patient volume, and the use of "care extenders" can reduce the time for the patient-therapist interactions that appeared to contribute to satisfaction.
The results of their study showed that patient satisfaction with care was most strongly correlated with the quality of patient-therapist interactions. This includes the therapist:
spending adequate time with the patient
demonstrating strong listening and communication skills
offering a clear explanation of treatment.
Note that the commonly cited “important factors” such as clinic location, fancy equipment, and close parking are less important in determining patient satisfaction.
Steve George published a nice paper examining the difference between satisfaction with treatment effect versus satisfaction with treatment delivery for the low back pain patient.2 His findings suggested that patient satisfaction is a multidimensional construct and that a patient being "satisfied" with care may have little to do with whether the patient is actually better.
Hush, Cameron and Mackey explored this theme in great depth in their 2011 publication “Patient satisfaction with musculoskeletal physical therapy care: a systematic review”. 3
This systematic review explored what the collective findings of multiple studies could tell us about the importance of the subjective experience of the patient. Not surprisingly, all the studies examined by the researchers identified therapist attributes as the critical dimension of patient satisfaction, attributes such as:
Professionalism
Competence
Friendliness
Caring
Ability to communicate effectively (e.g. offering a clear explanation of treatment)
Spending adequate time with the patient
Demonstrating strong listening skills
Note that these are all therapist attributes, not treatment attributes. In short hand, you might call this “the relationship”. And truly, any therapist worth his or her collective salt could tell you how essential the rapport established is to the success of intervention.
Call it the “Christmas cookie” phenomenon. The more likely the patient is to bring in a batch of cookies at the holiday, the more vested the patient is in the relationship, thus elevating the likelihood of a positive outcome. Some therapists may choose to sneer at such archaic ideas as rapport, but it’s hard to argue with the published evidence.
The researchers found that patient satisfaction was infrequently and inconsistently associated with the treatment the patients received. Strangely, actual changes in physical status had little to do with how patients rated the success of their intervention. In general, patients who felt comfortable with their therapist, who liked their therapist, who believed they were being treated as an adult, and who felt like they were being shown how to actively participate in treatment were more likely to feel satisfied with their outcome.
When patients were asked about what other factors made for a maximally satisfying treatment, their answers were not earth shattering. In general, they were:
More satisfied when the treatment duration was adequate (read: longer)
More satisfied when treated by the same practitioner every session
More satisfied working with PTs compared with physicians (especially when teaching elements were involved)
More satisfied with treatment provided in private clinics compared with not-for-profit, hospital-based facilities
And while treatment attributes might matter to some extent (for instance, patients were as satisfied with exercise as they were with manual therapy, massage, or electrotherapies), the intervention itself was not KING. Time and time again, patients turned their eyes to the importance of the relationship with their therapist.
The Closing Pitch
Those of us lucky enough to spend our days in the water are in an enviable position. All told, the pool is a wonderful place to do both: produce patient improvement while ensuring patient satisfaction. Not only are we allowed to touch our patients, we are expected to do so. We get to combine a specific (hopefully therapeutic) intervention with touch. We get to look into our patient’s eyes, listen to their woes, and spend our 1:1 time together explaining the science behind their treatments and our hopes for their future.
And, at the end of the day, we get to eat cookies. This, well THIS, is a world I want to live in.
References
Beattie PF, Pinto MB, Nelson MK, Nelson R. Patient satisfaction with outpatient physical therapy: instrument validation. Phys Ther. 2002;82:557-65.
George SZ, Hirsh AT. Distinguishing patient satisfaction with treatment delivery from treatment effect: a preliminary investigation of patient satisfaction with symptoms after physical therapy treatment of low back pain. Arch Phys Med Rehabil. 2005 Jul;86(7):1338-44.
Hush JM, Cameron K, Mackey M.Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Phys Ther.; 2011 Jan; 91(1):25-36.